Achieving Success with Knee Replacement

A successful early recovery can be achieved by first ensuring the patient’s knee condition warrants surgery. Patients electing to have surgery too early in the course of their arthritis may have little or no benefit in comparison with patients waiting until the appropriate time(2). Conversely, patients waiting too long to have the procedure may have increased their risk of additional disability and chronic disease as a result of not having surgery sooner(2). Your knee radiographs, the impairments in your physical activity, your response to nonsurgical treatments, social factors, and the examination of your knee all contribute to the correct shared decision about when to have surgery.

Furthermore, ensuring that medical conditions are optimized is important to predicting success with knee replacement. Ensuring blood sugars are well controlled, cardiac conditions are stable, and that the patient is at an appropriate weight to undergo an operation are critical. Individuals with uncontrolled medical conditions should be optimized prior to undergoing surgery to prevent complications like infection(3,4) revision surgery (3,4), heart attacks, or stroke.

There is mounting experience with “fast track” joint replacement, where patients may leave the surgical facility the same day or the day following surgery(5). We now have improved processes to successfully control pain without opioids, limit blood loss, and ensure early mobilization after knee replacement, leading to improved safety, outcomes, and satisfaction(5). Standardized protocols that use spinal (instead of general) anesthesia, anesthetizing nerve blocks, and numbing injections during surgery can ensure the patient is comfortable and able to safely walk immediately following the procedure. Surgical factors such as ensuring the knee is balanced and freely moving through a range of motion, which can be achieved with appropriate technique and use of robotic arm assistance(6) may help in the early period when walking and range of motion are initiated.

Two surgical factors that will help limit the rate of blood loss include the use of intravenous tranexamic acid, which is safe and works on the body’s clotting system, and avoidance of the use of a tourniquet. A tourniquet is a device that straps onto the thigh and effectively cuts off circulation to the limb to ensure a bloodless surgical field. Surgeons historically prefer a tourniquet because the surgery is faster and attention does not need to be paid to controlling bleeding from tiny vessels during surgery. However, data has confirmed these patients may bleed more after the surgery(7), requiring more transfusions(7), stay in the hospital longer(7), and have greater pain after surgery(8) because the leg is recovering from ischemia, where the leg effectively has no blood supply for up to or more than an hour during surgery. You should ask your surgeon if he or she uses a tourniquet during surgery and what the reasons are.

Historically, individuals having a knee replacement had an IV drip of narcotic pain medication and stayed in the hospital for days. Not the case anymore. With the advent of early “fast track” joint replacement with multi-modal techniques of improving pain symptoms, patients are up and walking the day of surgery. With the use of robotic technology(6), the knee is already moving in a smooth and balanced fashion before the patient is out of the surgical suite.

With a nurse and physical therapist, you will be up and walking with a walker within hours of surgery, allowing you to get to the bathroom and use stairs. Once you are safely walking and independent, you can discharge from the facility, sometimes the same day or the day after. You can resume full independent activities at home with assistance of a home health worker that checks on you at home for a couple weeks prior to starting physical therapy in the clinic. The walker is discontinued once you have the strength and confidence of normal walking, usually around four weeks.

Once you resume full activities by 6-8 weeks, the knee will continue to improve in a gradual fashion for the next several months. Physical therapy is usually discontinued by two to three months after surgery when you can resume sporting activities like biking or golf. As the knee strengthens, more impactful activities are possible including skiing and tennis. The goal is to continue to stay active. You can take walks outside and continue with home exercise until you almost forget about your knee, which generally occurs between 6 months and one year following surgery(9).