Adult Reconstruction

Arthritis is one of the most common causes of joint pain. There are many types of arthritis, including:

• Osteoarthritis (OA) This is sometimes called degenerative joint disease (DJD), also commonly referred to as “wear and tear” arthritis. The cartilage in the joints wears away, leaving the bones to rub against each other. This causes pain and stiffness. It tends to be more severe as one ages, although, it rarely is severe enough to warrant joint replacement until after age 55-65 years.
• Rheumatoid arthritis (RA) This is a disease that causes the lining of the joints to become thickened and inflamed. The end result is loss of cartilage, pain, and stiffness. RA affects women about three times more often than men. It may also affect other parts of the body besides the hip.
• Post-traumatic arthritis This may develop after an injury to the joint that does not heal properly, such as a broken bone fragment that extends into the joint or torn ligament. The joint surface is no longer smooth, which leads to more wear on the irregular joint surfaces.
• Osteonecrosis, or avascular necrosis (death of bone tissue) This is not a type of arthritis, but it may lead to arthritis. The bone cells beneath the cartilage die, and in most cases, the bone eventually breaks down and collapses or fragments. This results in a flattened joint surface, causing further pain, stiffness, and loss of the remaining cartilage (arthritis).
  
  The exact cause is unknown, but the problem often occurs after steroid (e.g, prednisone) usage given systemically through pills or an intravenous infusion route. Steroids given as an injection into a joint, muscle, or tendon stay mostly localized and have much less systemic impact and therefore are rarely associated with osteonecrosis. Additional causes include alcohol intake, bone marrow disease (such as sickle cell disease), blood clotting disorders, or abnormal blood flow within the bone due to an injury.
  • In the hip joint, the bone cells in the "ball" (femoral head) die, and the bone often eventually collapses or loses its round, spherical contour. The process can be painful. When the ball loses its round shape, it no longer fits well in the hip socket. 
  • In the knee joint, the bones most often affected are the lower end of the femur (femoral condyle) and upper portion of the tibia.  
     
• Septic arthritis This occurs when an infection develops within the joint. The infectious process results in the destruction of the cartilage and subsequent arthritis.
• Arthritis due to a tumor of the joint lining Tumors that arise from the joint lining (synovium) can create cavities within the bone and cartilage of a joint thereby causing arthritis. 

Using a drug or device “off label” means that the drug or device is being used for an indication or reason that is different from what was specified in the original FDA (US Food and Drug Administration) approval. Off-label prescribing of a drug or device is both legal and commonly done. Sometimes, the FDA will approve a drug or device for one purpose and doctors then find it works for another condition. When used for these other conditions, it’s considered “off-label” usage. It does not automatically mean there is substantial risk or that your doctor is experimenting on you. Risk is generally a greater concern if the drug or device is being used in a way that has rarely ever been done before.

For more information, please view the FDA's official website.

These terms are used interchangeably when talking about joint reconstruction surgery. Strictly speaking, replacement specifically refers to the removal of a joint surface and reconstruction using an artificial implant, whereas arthroplasty refers to the reconstruction of a joint using both artificial implants and any other biologic techniques, regardless of whether or not an implant is used. 

The hip is a ball and socket joint. The ball is the large, round upper end of the thigh bone (femur). This fits into a cup-like socket (acetabulum) on the outer side of your pelvis, or hip bone. 

The bones of the hip joint are covered with a layer of cartilage, a smooth, tough tissue that keeps the bones from rubbing together (you've probably seen cartilage on the end of a chicken bone “drumstick”). Muscles and ligaments (tough bands of tissue) surround the joint and hold the ball in place inside the socket.

Symptoms tend to get worse over time. However, you may have good days/weeks/months and bad ones, and your symptoms may change with the weather. 

The most common symptoms of hip arthritis are:

• Pain with activities (the pain is usually in the groin area and can spread to the knee)
• Limited range of motion
• Stiffness of the hip
• Walking with a limp

Total hip replacement (or arthroplasty) is surgery to replace the ball and socket of the hip joint. First, the surgeon removes the top part of the thighbone (femur). They replace this with an artificial ball, usually made of metal. This attaches to the top of a metal stem, which fits inside the thigh bone. 

Next, the surgeon removes some bone from the hip socket, along with any cartilage that remains. A new socket is put in its place. The new ball fits into the new socket so that the joint can move smoothly, without causing pain.

The decision to have this surgery is a "quality of life" choice. Many people choose the undergo a hip replacement when they find they can no longer do the things they used to enjoy. When hip pain keeps you from basic, everyday activities—like walking, getting in/out of a car, reaching down to your foot or tying shoes, shopping, or recreational activities such as bike riding —you may want to consider surgery. 

You and your surgeon will make this decision together after considering:

• How bad your symptoms are
• How much cartilage has been lost
• Your age
• Your overall health
• Your risk in having anesthesia and surgery

If you have a hip replacement, your new joint will be chosen to meet your particular needs. Though it will be made of the ­most durable materials available, it will eventually wear out if you live long enough. Studies show that, in people over 65, the first hip replacement will last at least 10 years in 90 to 95 percent of patients. It will last at least 20 years in 80 to 85 percent of patients. Some factors may shorten the lifespan of an artificial hip joint. For example, the new hip may not last as long in someone who:

Some factors may shorten the lifespan of an artificial hip joint. For example, the new hip may not last as long in someone who:

• Is overweight
• Is very active
• Is younger (for example, under age 65)
• Has poor bone quality
• Has had the same hip replaced before
• Has had a prior infection in the hip

As with any surgery, hip replacement carries some risk. Problems can happen either early or late after surgery. Serious problems are uncommon, but they do occur.

Early complications include:

• Infection
• Dislocation (when the ball pops out of the socket)
• Hemorrhage (severe bleeding)
• Nerve or blood vessel damage
• Blood clot
• Anesthetic complications, which can happen with any type of surgery

Late complications include:

• Infection
• Dislocation
• Loosening of the joint
• Reactions to the foreign material

Medical research has shown that the risk of infection and wound healing problems can be reduced by losing excess body weight, controlling elevated glucose levels for diabetic patients, stopping any immunosuppressive drugs such as steroids or other drugs used to treat autoimmune conditions (e.g., rheumatoid arthritis, psoriatic arthritis, lupus, Crohn’s disease, etc.), maintaining proper nutrition, eradicating infections elsewhere (e.g., the mouth and teeth), clearing skin rashes or cuts near the surgical site, and stopping all forms of nicotine usage (e.g., smoking, snuff, patch, gum, candy, etc.). 

In addition, anesthetic risks can be reduced by optimizing your lung and heart function and treating any modifiable conditions, such as low blood count (anemia). All of these interventions should be undertaken before your surgery is performed.

• Obtain clearance for surgery from your primary care doctor or our PAC (Pre-operative Assessment Center). 
  • At this appointment you should go over all of your medications and when they should be stopped before surgery. 
  • This appointment should be done around 3 weeks before surgery, but must be done within 30 days of surgery. 
• Attend the joint replacement preoperative teaching class.  
• Read the joint replacement handbook. 
  • This contains exercises that are beneficial to perform before and after surgery.
• See your dentist and complete any dental procedures before surgery
• Sign up for the Get Well Loop on MHealth’s website.  This free, online tool helps guide you throughout your surgical journey. 
• Sign up for MyChart on MHealth’s electronic medical records website to facilitate online communication.
• Make a plan for your recovery at home after hospital discharge..
  • Obtain durable medical equipment that will help your recovery. Amazon typically sells kits with helpful items. 
    • Such items include an elevated toilet seat with arms, a walker, crutches, a cane, a shower stool, a device to reach for objects, a device to help put on socks, a leg lifter to help you move your leg in bed, and a pair of slip-on shoes with a good sole or tread.
•  Ensure your bed is high enough in elevation to ease sitting, getting up, and avoiding excessive hip bending. A mattress height level at least as high as your upper thigh or buttock is recommended.
• Pick up any loose carpets to avoid tripping hazards
• Make your home as handicapped accessible as possible. For example, a hand-held shower spray/hose is useful.
   

Some patients may be able to go home on the same day of surgery. Candidates for our “same day discharge” outpatient program are generally healthy and have never had a hip implant before. Advances in pain relief and anesthetic techniques have greatly reduced the discomfort after hip replacement surgery, thereby precluding the need for intravenous pain medications and enabling a discharge to home.

Most average or typical patients will stay overnight for nursing care and physiotherapy and then depart for home the next day. Some patients with more complicated health problems or surgeries, such as reoperations or revision surgery, will stay longer. When leaving the hospital, most patients can go back home if they have someone there who can help them. Some may need to spend a few days at a transitional care unit (rehabilitation center). Usually, there is no need for a long-term stay in a skilled nursing facility.

Stays at skilled nursing or rehab facilities cannot be arranged before and are not guaranteed. Because of this, we want everyone to have a safe plan for after surgery. This includes someone to drive you home from the hospital and someone who is able to stay with you for 4-5 days after surgery. Eligibility for skilled nursing or rehab facilities is evaluated post-operatively. Bed availability is limited, insurance coverage differs based on your plan/coverage, and finding a bed/placement is not guaranteed. 

Besides the medicines you were taking before the surgery, you will take:

• Blood-thinning medicine, such as aspirin, apixaban (Eliquis), warfarin (Coumadin), or enoxaparin (Lovenox) for one month after surgery to help prevent blood clots.
• Pain medicine, such as oxycodone or hydrocodone (Vicodin), for several days or weeks after surgery. In general, narcotic medications are not prescribed beyond one month after surgery.
• Stool softeners are often helpful as the narcotic pain medication can cause constipation.  Two common medications available without a prescription include MiraLAX® (avoid if you are on dialysis) and Docusate (Colace®).

This varies with each person and the findings at surgery. In most cases, patients can apply full weight on the hip immediately after surgery. However, for balance and safety, you will use a walker/crutches/cane for roughly 1-4 weeks after surgery. You can drive a car in four to eight weeks. Most people increase their activities slowly. They can often play golf, doubles tennis, or go bowling after twelve weeks. More active sports, such as singles tennis and jogging, are not recommended.  

Once you have recovered to the point when you don’t need any pain medication, it’s probably fine to have sex. However, it’s important to avoid body positions that would increase the risk of a hip dislocation. For women, lying on your back with legs spread apart (missionary position) is the safest position. For men, either the top or bottom position is fine as long as you keep your knees spread apart at least as wide as your shoulders.  

It depends on the type of work you do. If you work at a desk, you may be able to return to work within a few days after surgery, although your attention span may be reduced if you are still taking pain medication. If you need to travel or commute to work in a car, it’s best to wait at least a few weeks or a month. If your work is physically demanding, it may be as long as three months.

Right after surgery, getting out of bed and taking your first few steps will be a challenge, but after that, it gets easier. Patients who have hip replacements often need much less physical therapy than those who have knee replacements. You will work with a physical therapist while you are in the hospital. Few patients need physical therapy after they leave and go home

Walking will be the most important activity for your recovery. In the hospital, you will learn how to use a walker. We will tell you whether to put full or partial weight on the hip. When you feel stronger, you can advance to walking with a cane or crutches. You should use either crutches or a cane for the next six weeks. Typically, a cane is used in the hand on the opposite side from the replaced joint and placed on the ground whenever you step on the leg with the replaced joint.

Stich Care & Management

Your incision may be closed with staples, metal clips, non-dissolvable stitches (black), or dissolvable stitches (brown, tan, clear). There may be no visible stitches along the incision line, with the exception of a portion at either end of the incision, the “tail” of a stitch (often looks like a clear fishing line). In this case, the stitch is woven under the skin. You may cut the external “tail” off at any time by pulling it taut and cutting it with scissors at the level of the skin (like trimming a hair), thereby letting the remainder retract within the skin (it will dissolve over a few months).  For other non-dissolvable stitches or clips, these should be removed 10 to 14 days after surgery.

The incision is frequently taped together with white tapes (steri-strips) or sealed with a clear glue film (like "Crazy glue”). The film of glue will peel off over a few weeks, similar to dead skin after a sunburn. The white steri-strips often have some darkened dried blood staining them and may be removed whenever they start to curl up and fall off themselves.

Bandage Management

It’s best to keep the surgical incision sterile by wearing your original bandage dressing as long as possible, typically a week, but a minimum of 3-4 days. Change the dressing and re-apply gauze with tape if the original dressing is not sealing the incision anymore for any reason. After the 3-4 day minimum, if desired, you may take the bandage off if the wound is dry (when there is no blood or fluid actively oozing from the wound).

Bathing & Cleanliness

For showering, you may get the incision wet when (1) the incision is dry and without any drainage AND (2) the drain tube, if any, has been removed AND (3) the bandage has been removed. Until then, bathe with a washcloth and basin. When you start showering, avoid rubbing the incision too briskly when washing or drying. Pat the incision dry rather than rubbing it with a towel.

Your first follow-up visit will usually be one month after surgery. At that time, we will ask you to stop taking your blood-thinning medicine. We will take an X-ray of your hips and check how well the wound is healing. 

In most cases, if there are no issues that require monitoring by your surgeon, you will schedule your next visit one year from your surgery date.

You will need to protect your hip to prevent the ball from coming out of the socket. For the first 6 weeks after surgery, you should:

• Keep your knees at least shoulder-width apart.
• Do not cross your knees or legs.
• Do not sit with your knees held together.
• Do not bend your hips beyond 90 degrees.
• Do not sit in seats lower than your knee level (deeply cushioned sofas or chairs, reclining chairs, desk chairs, low beds, low toilets).
• Do not sleep on your side.

We will go over these and other rules before you leave the hospital.

Remember, the seating of the ball in the socket of your new hip isn’t fully secure until the surrounding tissue enveloping the hip joint has fully healed.  After 6-12 weeks, the soft tissue around the hip will heal and grow strong enough to gradually allow more motion and flexibility while keeping the ball in the socket.  

With a traditional total hip replacement, the surgeon removes the entire ball and the top 3- to 4-inches of the thigh bone (femur). The surgeon will also remove the bone inside the canal for an additional 4- to 8-inches of the upper thigh bone. This is to make room for the implants’ artificial stem. With a hip resurfacing replacement, only the cartilage surface is removed, sparing much more of the amount of bone removed. Surgeons remove the least possible amount of bone and then reshape the ball and socket. Resurfacing is analogous to re-treading a car tire instead of replacing the entire wheel and tire. The new ball (femoral head) is larger than that used in a traditional total hip replacement and more closely matches the natural joint. This results in a greater range of movement and lower risk of dislocation.

There are two kinds of hip resurfacing: partial or total. Partial resurfacing replaces part of the ball only. Total resurfacing replaces parts of both the ball and the socket. Preserving bone is most attractive to young, active patients who are likely to outlive their first hip replacement and eventually require a new one. A subsequent, second (revision) hip replacement is easier and has greater durability when there's more of the original bone present. However, resurfacing is not right for everyone. Sometimes the head of the thigh bone is too damaged to hold the resurfacing component and in addition, the metal ions shed into the surrounding tissue occasionally may cause an inflammatory reaction.  Your surgeon may advise you of the pros and cons of a resurfacing vs conventional type of hip replacement.

These terms refer to the surgical approach or access pathway between your skin and the hip joint. Traditionally, hip replacement used a 6-to-8-inch incision over the buttock and side of the thigh.The length depended on the size of the patient. This type of surgery has been done for over 40 years. The success rate is above 90 percent even 10 years after surgery.

Minimally invasive hip replacement has been new since around 2003. There is no accepted definition of "minimally invasive"—it means different things to different surgeons. It can mean:

• Traditional surgery completed through a slightly smaller incision (say, 3-to-5 inches rather than 6-to-8 inches)
• A much smaller incision, often termed “minimal incision” (such as around 3 inches).
• Two 1½-inch incisions on the front and back of the hip (surgeons use an X-ray machine to find and replace the bones)

Direct anterior hip exposure refers to putting the incision on the front of the hip slightly off to the side of the groin and splitting the muscles in the front of the hip to gain access to the joint.   While the incision length is similar to incisions used for a posterior hip exposure, the surgical pathway to the hip cuts fewer muscles and is associated with a slightly faster recovery in the first few months, however, after 1 year, there is no difference in the hip function and recovery as compared to the posterior hip exposure. 

Direct anterior hip exposure is associated with different complications such as painful thigh numbness, a higher risk of anterior hip dislocation, and a higher risk of skin wound breakdown as compared to posterior hip exposure.  Some body shapes, such as a large belly, are unsuited for direct anterior hip exposure.

The posterior hip exposure can be done with the same incision length as the direct anterior hip exposure. As this historically was developed before the direct anterior hip exposure, it has a longer track record of success than the direct anterior hip exposure. The posterior exposure is also considered to be a more versatile approach than the other approaches by many surgeons. At 6-12 months after surgery, the functional outcome and recovery are the same as the direct anterior hip exposure. However, there is a higher risk of posterior hip dislocation as compared to direct anterior hip exposure.  

Choosing Your Surgery Type

Your choice of surgery is a personal one best made in view of all the facts and recommendations given by your surgeon. At the University of Minnesota, there are surgeons who perform hip replacements using any of the above-mentioned techniques and exposures.  

Your surgeon will review your specific situation and consider all aspects of your care, including your planned activities and needs after surgery, your body shape and size, your type of joint arthritis, any deformities in your bone, your age, and your overall medical health before providing a recommendation to you. 

When making decisions about hip replacement surgery, keep in mind that your choice of surgeon is probably the most important choice you’ll make rather than the technical aspects of surgical exposure, incision type, or hip implant design, brand, or material. Important considerations in your hip surgeon are the level of confidence you have in them (based on training, experience, and reputation), your assessment of how caring they are, and their ability to communicate effectively and listen to you. 
 

It is possible to replace both hips at the same time. However, replacing both hips together may increase the risk of surgery and put slightly more stress on your heart and lungs. Surgeons differ in their opinions on this issue. 

If both hips need to be replaced, we recommend staging both operations on two different dates, often doing the second hip roughly one month after your first hip surgery. 

Some replacement implants attach to the bone with cement; others do not.

Cemented joints were developed over 50 years ago. They are most often used for older, less active people and for people with weak bones, such as those who have osteoporosis (brittle bone disease). Cemented joints are rigidly fixed within the bone immediately after surgery and as such, reduce pain and increase joint mobility. However, they may loosen over time, and microscopic cement particles will sometimes break off over time resulting in erosion of the surrounding bone.

Uncemented joints were perfected after cemented fixation of implants already existed. The improvement goal was to increase the durability of the implant's fixation to the natural bone. 

At the present time, surveys among surgeons indicate that most surgeons tend to use uncemented joints in younger, active patients with stronger bones, with the intent of providing a more durable implant. However, uncemented joints are associated with a slightly higher risk of developing small bone cracks during implantation (up to 5-10% of cases) and thigh pain for several months after surgery in 10 to 20 % of patients. This pain usually resolves spontaneously, but in rare cases, it requires a repeat operation.  

Doctors will sometimes use a "hybrid" joint, which consists of a cemented ball and an uncemented socket. Because each person is unique, the doctor and patient must weigh the advantages and disadvantages to decide which type of joint is best.
 

Most new joints are made of metal (such as cobalt chrome or a titanium alloy) and plastic (ultra-high molecular-weight polyethylene, highly crosslinked). Surfaces where the ball and socket rub together are usually made of special plastic, ceramic material, or cobalt chrome metal. Most hip implants are modular with a metal socket and an inner removable bearing made of a plastic polymer. The ball (femoral head) is usually made of either ceramic or cobalt chrome metal and is attached to a titanium metal stem implant that is embedded into the thigh bone (femur). This combination has a proven track record of lasting many years in a majority of patients. Many material surfaces have been tried in the 40 or so years that hip replacements have been done. 

The most common materials used today include:

• Polyethylene (plastic) This is a durable, high-performance plastic resin. It is slippery, which is why it works well in a mobile joint like the hip. But it is known to wear out. When this happens, it sometimes causes bone loss around the joint. This can make repeat hip replacements (called revision surgeries) more difficult. A new type of polyethylene, called highly crosslinked polyethylene, may not wear out as quickly.  Additives such as antioxidants like vitamin D are also used to reduce the wearing out of the polyethylene.  
• Ceramic Ceramic surfaces may last longer than plastic or metal.  However, the ceramic material has been known to break and chip occasionally (similar to glass breaking). When this occurs, the small ceramic pieces may be difficult to remove from the joint. Usually, a repeat operation needs to be done without delay. Most often, a ceramic material may be used for the ball and rarely it is used in a socket implant.
• Metals Metal surfaces are used regularly for the implant components that are embedded into a bone as the bone can grow and attach to some metal substrates (titanium or cobalt chrome metals).  For a socket’s inner bearing surfaces, metal rubbing against metal is being done much less often than decades ago. Presently, implants commonly made of titanium or cobalt chrome materials are used most often.

The choice of surface is still somewhat controversial. Reasonable scientists, surgeons, and patients will sometimes disagree. This is one of the most exciting areas of research in the field of hip replacement surgery. At the University of Minnesota, surgeons will consider many factors in selecting implants and use both long-term research data and patient-specific factors to select the optimal implant for your situation.  
 

The knee is a hinge joint that provides motion where the thigh meets the lower leg. The joint is made up of three bones held together by tough bands of tissue called ligaments which keep the knee moving in the proper direction. The thigh bone (femur) makes up the top part of the joint. It meets the shin bone (tibia) at the lower part of the joint. In front of these bones is the kneecap (patella), a round bone that helps the joint work better. 

The kneecap glides in a groove on the front surface at the end of the thigh bone whenever you bend or straighten your leg. The thigh bone and shin bone are separated by cartilage, a smooth, tough tissue that keeps the bones from rubbing together. (You've probably seen cartilage on the end of a chicken bone “drumstick”.) The cartilage acts as a cushion. It allows the two bones to move together so you can bend your knee.

Symptoms tend to get worse over time. However, you may have good months and bad months, and your symptoms may change with the weather. 

The most common symptoms of knee arthritis are:

• Pain with activities
• Limited range of motion
• Stiffness and swelling of the knee
• A deformed knee — it may bow in or out
• Feeling the knee "giving-way" or buckling uncontrollably 

Total knee replacement, or arthroplasty, is surgery to replace the diseased knee joint. The surgeon removes the surfaces along the bottom of the thigh bone (femur) and the top of the shin bone (tibia). Then they resurface the bone ends with metal and plastic. The surgeon may also add a plastic disc "button" under the surface of the kneecap (patella) if needed.

The knee can be divided into three sections, or compartments:

• The inside of your knee (medial compartment)
• The outside of your knee (lateral compartment)
• The area where your kneecap rests (patello-femoral compartment)

If your knee is damaged only on the inside or outside, but the rest of the knee is healthy, you might be able to have a partial knee replacement. This is sometimes called a unicompartmental knee replacement.

This surgery replaces only the damaged part of your knee. It is much less invasive than total knee replacement. It may require fewer days in the hospital, and recovery time is often much faster.

It is technically possible to replace both knees at the same time. But doing both knees together may increase the risk of surgery and put slightly more stress on your heart and lungs. Surgeons differ in their opinions on this issue. 

In general, while this is an option for healthier patients, most patients would incur less risk by having one knee done first with the second one done later after a month or so.     

The decision to have this surgery is a "quality of life" choice. You may want to consider knee replacement when most of the following are true:

• Your knee pain keeps you awake, or wakes you up, at night.
• Your knee pain limits your daily activities, making it hard to get up from a chair, climb stairs, etc.
• Your knee pain limits activities that give you pleasure (walking for exercise, traveling, shopping).
• You have tried other treatments (medicines, a cane, braces, even changing activities), but you still have knee pain.
• X-rays of your knee show areas of complete cartilage loss or damage.
• The knee joint is likely to last for the rest of your life.
• You are willing to accept the risks that come with total knee replacement.

You and your surgeon will make this decision together after considering:

• How bad your symptoms are
• How much cartilage has been lost
• Your age
• Your overall health
• Your bone density
• Your risk in having anesthesia and surgery

As with any surgery, knee replacement carries some risk. Problems can happen either early or late after surgery. Serious problems are uncommon, but they do occur.

Early complications include:

• Infection
• Hemorrhage (severe bleeding)
• Nerve or blood vessel damage
• Blood clot
• Anesthetic complications, which can happen with any type of surgery

Late complications include infection and loosening or wearing out of the joint.

Medical research has shown that the risk of infection and wound healing problems can be reduced by losing excess body weight, controlling elevated sugar (glucose) levels for diabetic patients, stopping any immunosuppressive drugs such as steroids or other drugs used to treat autoimmune conditions (e.g., rheumatoid arthritis, psoriatic arthritis, lupus, Crohn’s disease, etc.) or cancer, maintaining proper nutrition, eradicating infections elsewhere (e.g., the mouth and teeth), clearing skin rashes or cuts near the surgical site, and stopping all forms of nicotine usage (e.g., smoking, snuff, patch, gum, candy, etc.).  

Anesthetic risks can be reduced by optimizing your lung and heart function and treating any modifiable conditions, such as low blood count (anemia).  All of these interventions should be undertaken before your surgery is performed.

If you smoke, stop! Even quitting the week before surgery will help reduce your risk of lung problems and blood clots. To further prevent blood clots, you will need to start moving your foot and ankle again right after surgery. We will also give you blood-thinning medicine to help keep blood clots from forming.

Infection is a lifelong risk after a knee replacement. An infection causing illness in one part of the body—such as the skin, teeth, respiratory tract or urinary tract—can cause an infection around the new knee joint. If you have any kind of infection, you need to tell your doctor right away. You will also need to take antibiotics before having dental work or any surgical procedure that could allow germs to enter your bloodstream.

If you have a knee replacement, your new joint will be chosen to meet your particular needs. Though it will be made of the most durable materials available, it will eventually wear out if you live long enough. Studies show that, in people over 65, the first knee replacement will last at least 10 years in 90 to 95 percent of patients. It will last at least 20 years in 80 to 85 percent of patients. Some factors may shorten the lifespan of an artificial knee joint. 

For example, the new knee may not last as long in someone who:

• Is overweight
• Is very active
• Is younger (for example, under age 65)
• Has poor bone quality
• Has had the same knee replaced before
• Has had a prior infection in the knee 

• Obtain clearance for surgery from your primary care doctor or our PAC (Pre-operative Assessment Center). 
  • At this appointment you should go over all of your medications and when they should be stopped before surgery. 
  • This appointment should be done around 3 weeks before surgery, but must be done within 30 days of surgery. 
• Attend the joint replacement preoperative teaching class.  
• Read the joint replacement handbook. 
  • This contains exercises that are beneficial to perform before and after surgery.
• See your dentist and complete any dental procedures before surgery
• Sign up for the Get Well Loop on MHealth’s website.  This free, online tool helps guide you throughout your surgical journey. 
• Sign up for MyChart on MHealth’s electronic medical records website to facilitate online communication.
• Make a plan for your recovery at home after hospital discharge..
  • Obtain durable medical equipment that will help your recovery. Amazon typically sells kits with helpful items. 
    • Such items include an elevated toilet seat with arms, a walker, crutches, a cane, a shower stool, a device to reach for objects, a device to help put on socks, a leg lifter to help you move your leg in bed, and a pair of slip-on shoes with a good sole or tread.
•  Ensure your bed is high enough in elevation to ease sitting, getting up, and avoiding excessive hip bending. A mattress height level at least as high as your upper thigh or buttock is recommended.
• Pick up any loose carpets to avoid tripping hazards
• Make your home as handicapped accessible as possible. For example, a hand-held shower spray/hose is useful.

Some patients may be able to go home the same day of surgery. Candidates for our “same day discharge” outpatient program are generally healthy and have never had a knee implant placed in the knee before. Advances in pain relief and anesthetic techniques have greatly reduced the discomfort after knee replacement surgery, thereby precluding the need for intravenous pain medications and enabling a discharge to home.

Most average or typical patients will stay overnight for nursing care and physiotherapy and then depart for home the next day. Some patients with more complicated health problems or surgeries, such as reoperations or revision surgery, will stay longer. When leaving the hospital, most patients can go back home if they have someone there who can help them. 

Some may need to spend a few days at a transitional care unit (rehabilitation center). Usually there is no need for a long-term stay in a skilled nursing facility.

Yes! Physiotherapy is continued after hospital discharge either in an outpatient setting or in the home. It is very important to perform exercises to regain the flexibility (range of motion) of the knee immediately after surgery in order to prevent permanent stiffness.

You should be able to apply full weight on the knee immediately after replacement as pain allows. Strengthening of the thigh muscle to straighten out the knee is very important as well.  

Therapists will be able to help teach and guide you through this recovery process. Depending upon your home location and insurance coverage, physiotherapy may be done either at a local office or by home visitation. We recommend scheduling your post-op outpatient physical therapy before your surgery date. These orders will be placed by your provider and we recommend setting up your first appointment 2-3 days after surgery.

Home physical therapy cannot be set up before surgery. If you are having trouble achieving the goal of bending the knee to 90 degrees by 4-6 weeks, your surgeon may help out by performing a manipulation of the knee while you are briefly sedated by an anesthesiologist.

Your activity program should include:

• Walking a little farther each day, first in the home and later outside.
• Getting back to your normal daily movements, such as sitting, standing and walking up and down stairs.
• Exercising several times a day to restore movement and strengthen the knee.
• Fully straightening the knee and bending it to 90 degrees by 4 weeks after surgery.
   

This is called a continuous passive motion (CPM) machine and most surgeons have stopped using it routinely as studies have not shown a clear benefit after full recovery is attained 6-12 months after surgery. 

While it does automatically move the knee and help to decrease leg swelling by elevating the leg and improves venous circulation by moving the muscles of the leg, it cannot fully substitute for manually moving and stretching the knee yourself or with another person’s assistance. 

In selected cases, or patients with a prior history of difficulty performing exercises, it might be employed.
 

Besides the medicines you were taking before the surgery, you will take:

• Blood-thinning medicine, such as aspirin, apixaban (Eliquis), warfarin (Coumadin), or enoxaparin (Lovenox) for one month after surgery, to help prevent blood clots.
• Pain medicine, such as oxycodone, Percocet, or hydrocodone (Vicodin), for several days or weeks after surgery. In general, narcotic medications are not prescribed beyond one month after surgery.
• Stool softeners are often helpful as the narcotic pain medication can cause constipation. Two common medications available without prescription include MiraLAX® (avoid if you are on dialysis) or Docusate (Colace®).

This varies with each person. While most patients can apply full weight on the knee immediately after surgery, the use of a walker or crutches is advised for your safety and balance assistance.  

Most patients will transition to a cane very quickly in the first week or so and discontinue the cane altogether and walk without any aids 2-4 weeks after surgery. Some pain with activity and at night is common for several weeks after surgery. This will decrease over time.

An important goal to work towards is to fully straighten and bend the knee to a 90 degree angle by 4 weeks after surgery. Despite this fast recovery, there will be residual swelling around your knee for many months and it will gradually decrease during the first year after surgery. You will be able to go back to most of your daily activities within several weeks.

Most people can start driving again once they can bend the knee at least 90 degrees and are not taking any narcotic pain medication anymore.    
 

It depends on the type of work you do. If you work at a desk, you may be able to return to work within a few days after surgery, although your attention span may be reduced if you are still taking pain medication. If you need to travel or commute to work in a car, it’s best to wait at least a few weeks or a month. If your work is physically demanding, it may be as long as three months.

Right after surgery, getting out of bed and taking your first few steps will be a challenge, but after that it gets easier. Most people begin exercising their knee the day after surgery.

You will work with a physical therapist while you are in the hospital, and you will continue physical therapy after you leave, usually until you can bend the knee at least 90 degrees. Your goal should be to straighten the knee and to bend it 90 degrees within three to four weeks. Your activity program should include:

• Walking a little farther each day, first in the home and later outside.
• Getting back to your normal daily movements, such as sitting, standing and walking up and down stairs.
• Exercising several times a day to restore movement and strengthen the knee.

Stich Care & Management

Your incision may be closed with staples, metal clips, non-dissolvable stitches (black), or dissolvable stitches (brown, tan, clear). There may be no visible stitches along the incision line, with the exception of a portion at either end of the incision, the “tail” of a stitch (often looks like a clear fishing line). In this case, the stitch is woven under the skin. You may cut the external “tail” off at any time by pulling it taut and cutting it with scissors at the level of the skin (like trimming a hair), thereby letting the remainder retract within the skin (it will dissolve over a few months).  For other non-dissolvable stitches or clips, these should be removed 10 to 14 days after surgery.

The incision is frequently taped together with white tapes (steri-strips) or sealed with a clear glue film (like "Crazy glue”). The film of glue will peel off over a few weeks, similar to dead skin after a sunburn. The white steri-strips often have some darkened dried blood staining them and may be removed whenever they start to curl up and fall off themselves.

Bandage Management

It’s best to keep the surgical incision sterile by wearing your original bandage dressing as long as possible, typically a week, but a minimum of 3-4 days. Change the dressing and re-apply gauze with tape if the original dressing is not sealing the incision anymore for any reason. After the 3-4 day minimum, if desired, you may take the bandage off if the wound is dry (when there is no blood or fluid actively oozing from the wound).

Bathing & Cleanliness

For showering, you may get the incision wet when (1) the incision is dry and without any drainage AND (2) the drain tube, if any, has been removed AND (3) the bandage has been removed. Until then, bathe with a washcloth and basin. When you start showering, avoid rubbing the incision too briskly when washing or drying. Pat the incision dry rather than rubbing it with a towel.

Your first follow-up visit will usually be one month after surgery. At that time, we will ask you to stop taking your blood-thinning medicine. We will take an X-ray of your knee and check how well the wound is healing. 

In most cases, if there are no issues that require monitoring by your surgeon, you will schedule your next visit one year from your surgery date.

You will always need to protect your new knee. 

For example, you must not sleep with a pillow under your knee as this makes it harder to achieve straightening the knee fully. Instead, you should place a small pillow or towel under your ankle to keep the knee straight while sleeping. 

It will be very important to avoid falling in the first few weeks after surgery. A fall can damage your new knee and lead to more surgery. Until you improve your strength, balance, and flexibility, you will need a cane, walker, crutches, handrails, or someone to help you. 

Be very careful on stairs until your knee is strong and mobile. Your therapist will go over these and other safety rules.

Yes. Assistive devices will make life after surgery more comfortable. Your occupational therapist will help you get the equipment you need. This may include:

• Safety bars or a secure handrail for the shower or bathtub
• Secure handrails along stairways
• A raised toilet seat with arms
• A stable shower bench or chair for bathing
• A leg lifter to help you move your leg in bed

You will also need to set up a short-term living space with a bathroom on the same floor. It will be hard to walk up and down stairs early in recovery.

The surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling, such as a special support hose, inflatable leg coverings (compression boots), and blood thinners.