Definitive Physiotherapist’s Guide to Knee Joint Replacement Surgery

Introduction

This definite physiotherapist’s guide to Knee Joint Replacement Surgery will provide its readers with the following information:

• General insight into Joint Replacement Surgery and its Objectives
• Pre-operative guidance
• Day of surgery/’in-patient’ guidance
• Post-operative guidance
• Guidance of ongoing responsibilities to achieve the optimal outcome

General insight into Joint Replacement Surgery and its Objectives

A joint is a point of contact between two bones, allowing movement and providing support. A joint replacement is the surgical procedure for the replacement of a diseased or damaged joint surface with one made from artificial material. For more specific information about the knee joint, please click here.

Knee Joint Replacement Surgery involves replacing the surfaces of this hinge joint. Please view the images of a ‘normal’ knee (left image) and a knee following Joint Replacement Surgery (right image) below:

Knee Joint Replacement Surgery has become more common due to advances in the types of implants and materials. The operation can greatly improve quality of life because of pain reduction, increased mobility, and the correction of deformity. Medical advances in Knee Joint Replacement Surgery have also resulted in:

• Shorter ‘In-patient’ hospital stays for patients
• Longer lifespans of prosthetic components
• Quicker recovery
• Better outcomes – function, quality of life and satisfaction
• Reduced complication rates

To achieve the best outcome possible from Knee Joint Replacement Surgery, the evidence-base suggests that a proactive approach, both pre-operatively and post-operatively, should be taken to enhance recovery. The next part of this physiotherapist’s guide will outline these below.

Pre-operative Guidance

Pre-operative assessment appointment

Before Knee Joint Replacement Surgery, all patients will attend a ‘pre-op’ assessment appointment to go through the medical preparations for surgery. As part of this appointment, patients will see various members of the hospital team including the hospital physiotherapist who will run through the physiotherapy process for the day of surgery. It would be advised that patients use this appointment as a final opportunity to ask any questions they may have about their surgery.

The plan for post-operative physiotherapy care should be organised pre-operatively, i.e., the 1^st physiotherapy appointment following Knee Joint Replacement Surgery should be booked in advance of surgery. This ensures a smooth transition from ‘in-patient’ to ‘out-patient’, with no delays in the treatment pathway.

Exercising before Knee Joint Replacement Surgery

It is vital that patients undertake exercises before Knee Joint Replacement Surgery. Performing exercises before surgery brings very significant benefits. These include:

• Strengthening muscle groups before surgery that will be required to support and move your ‘new’ joint.
• Reducing the risk of complications after surgery.
• Helping to form new exercise habits – which is essential for post-op recovery.

For basic guidance on what types of exercises to do pre-operatively for Knee Joint Replacement Surgery, please click here.

Getting prepared at home before Knee Joint Replacement Surgery

It is advised that you get your house ready for coming home before Knee Joint Replacement Surgery. This might include:

• Doing laundry and putting it away
• Putting clean sheets on beds before leaving for Hospital
• Preparing and freezing meals in single servings
• Cutting the grass
• Fastening down loose carpets and taking up loose rugs
• If you have a pet, making sure that someone can take care of it for your first few weeks post-operatively if necessary

Eating well, getting plenty of sleep, reducing your alcohol consumption and/or stopping smoking before surgery has also been proven to enhance recovery.

Day of Surgery/'In-patient' Guidance

Day of surgery

Patients will be admitted to hospital on the day of their surgery. Once admitted, patients will be re-examined by a nurse and their orthopaedic surgeon, who will mark their leg and ask them to sign a consent form. Patients will be measured for anti-embolic stockings (TEDs), which promote circulation in the legs and prevent the formation of Deep Vein Thrombosis (DVT) or blood clots. Patients will also be measured for walking aids.

Patients will also be seen by the anesthetist before their operation. The anesthetist will examine them and discuss the type of anesthetic that will be used. A spinal anesthetic is typically used. A spinal anesthetic is critical for early mobilisation. For a while afterwards, patients who have this will have no feeling in their legs and won't be able to move them, but when the spinal wears off, function and feeling will return to normal. Spinal anesthesia has also the advantage of having a lower risk of developing deep vein thrombosis (DVT).

Depending on the orthopaedic surgeon’s protocol and pre-operative decisions, patients can expect to typically stay for 1-2 days in hospital following Knee Joint Replacement Surgery. Due to medical advances, some patients may even be discharged on the same day of their operation.

During in-patient stay

Whilst patients are in hospital following their Knee Joint Replacement Surgery, they will be instructed to complete bed exercises under the guidance of the ward physiotherapist. This is to help retain early movement in the new joint after surgery and gain a secure muscle contraction around the joint. The exercises undertaken pre-operatively will allow patients to achieve this better. Prior to discharge, patients who have endured Knee Joint Replacement Surgery, must aim for a minimum of 90 degrees or flexion (bend) and 0 degrees of extension (be able to achieve a straight knee).

Patients will also be shown/educated how to transfer from the bed and begin mobilising with a zimmer frame, before progressing onto elbow crutches. The technique for ascending and descending stairs with elbow crutches will also be educated before patients are allowed to be discharged safely.

Upon discharge, a letter will be sent to the patient’s GP including important information about the patient’s procedure and their condition on discharge. Information will also be given on when and how the wound staples/stitches need to be removed (if these are present) – this is typically undertaken at the patient’s GP by the GP nurse practitioner.

Patients will also be discharged with a certain amount of pain relief. This should be taken as prescribed and once it runs out, further pain relief should be sourced from their own GP. It is vitally important that patients continue with their exercises as soon as they are discharged home and before they are seen for their first ‘out-patient’ physiotherapy appointment. Sufficient pain relief plays an essential role in this.

Post-operative Guidance

Managing pain after Knee Joint Replacement Surgery

Due to the nature of Joint Replacement Surgery, pain is inevitable following the operation. Pain symptoms, the intensity, and the frequency, can vary from person-to-person. Pain symptoms need to be kept at a suitable level with pain management to ensure an acceptable level of movement is achievable, and pain should not prevent appropriate function e.g., Physiotherapy, Exercises and moving around. Pain control is therefore an integral part of post-operative care and is available in different forms and strengths. Patients should seek advice from their GP should they have any concerns about their pain relief.

Dressings and orthopaedic surgeon reviews

Dressings and staple/stitches removal (if used) typically takes place 2-3 weeks after Knee Joint Replacement Surgery. Patients will typically have a post-op review with their surgeon 6-8 weeks after their surgery to evaluate their progress. If happy, surgeons will then typically arrange another review at either 3 or 6-months post-op.

Outpatient physiotherapy and exercises at home

After Knee Joint Replacement Surgery, it is vital that patients attend a course of post-operative treatment. The 1st appointment for this is typically 5-10 days after your operation date.

The early phase of rehabilitation following Knee Joint Replacement Surgery focuses on:

• Improving the new joint mobility – movement is essential to function and without mobility in the joint, function is deterred – the goal for Knee Joint Replacement Surgery should be to achieve movement ranges of 0-120 degrees
• Gaining good quality of muscle contraction around your knee
• Improving and increasing your walking pattern and tolerance
• Controlling swelling

For basic guidance on what types of exercises to do post-operatively for Knee Joint Replacement Surgery, please click here.

The physiotherapist will discharge patients with the expectation that they can continue to self-manage with their taught exercises once suitable function has been achieved, e.g., patient is back engaged in normal activities of daily living (driving, walking unaided, returned to work etc).

There is strong belief that range of movement improvements can be achieved with a new joint for a window of up to 18 weeks. Following this period, whatever movement is present within the joint, will remain. This highlights the significance of pushing movement ranges within the new joint in the early part of the recovery post-operatively.

Managing swelling following Knee Joint Replacement Surgery

It is very important for patients to manage their swelling after surgery. Swelling can persist for up to 12 months following joint replacement surgery. Persistent swelling may cause tension in legs and limit movement capacity. The same tension can make it more difficult to contract the muscles needed to support the new joint. By managing swelling, pain symptoms can also be better managed.

The best physiotherapist tips for managing swelling are:

• Use ice packs or similar cryotherapy but be careful not to damage your skin – do not put cold packs onto open wounds.
• Elevate the affected leg with support, keeping foot higher than your heart, and perform ankle and foot movements.
• Carry out prescribed recovery exercises and move around regularly.
• Increase walking as advised by the physiotherapist.
• Avoid prolonged seating or standing for the first 6 weeks post-op.
• Avoid prolonged journeys (long haul) for the first 12 weeks post-op.

Typical timescales for returning to activities of daily living & hobbies

The typical timescales for returning to activities of daily living and hobbies are set out below:

• Driving – 6 weeks
• Air travel – avoid flights for 4 weeks before surgery, and for 12 weeks after surgery
• Swimming – breaststroke swimming - 3 Months. Gentle Front Crawl Leg Kick can be started earlier if the wound has healed, and your physiotherapist agreed
• Riding a bike – 3 months for road bike cycling
• Golf – 3 months
• Low impact exercise class – 6-12 weeks depending on progress

These timescales can offer patients a realistic guide of when they can expect to be undertaking such activities post-operatively.

Guidance of ongoing responsibilities to achieve the optimal outcome following Knee Joint Replacement Surgery:

Once patients have been discharged by their physiotherapist, they should continue to undertake their exercises independently for up to at least 18-weeks post-op, ensuring they achieve as much range of movement as possible in their new joint (aim for 0-120 degrees).

After this 18-week period, it would be strongly advised that continued exercise and use of the joint (in whichever form is preferred) is carried out to achieve the best outcome from their Knee Joint Replacement Surgery. This could come from using a stationary bike in the gym, or from simply undertaking a daily walk.

Full recovery from Knee Joint Replacement Surgery can take up to 18-24 months.

Summary

Using this guide, patients who are preparing for, and having Knee Joint Replacement Surgery, can ensure they have themselves in the best possible position physically and mentally, pre- and post-operatively, to overcome this major surgical procedure.

For any specific or more personal queries, it would be advised to contact your orthopaedic surgeon or a specialist physiotherapist to discuss these further. At the White House Clinic, we have a vast number of orthopaedic specialist physiotherapists who would be more than happy to assist.