Timeline of Recovery after Knee Replacement
The Timeline of Recovery
The nurses will make a final check that all your reports are in order and that you have taken the right medicines, stopped the blood thinners as you were advised, and you have all the required X-rays etc . and that you are starving for at least 6 hours. The vital signs that is your pulse, blood pressure, respiration rate will also be recorded to confirm that there are no last-minute surprises. The NURSES will report everything to the anaesthesia team as well as the medical team if required. The knee to be operated would be marked by an arrow to confirm that it is indeed the knee to be operated. This mark is very important. The knee will be washed again with the antiseptic solution and wrapped in a towel. You are advised to pass urine and empty the bladder before surgery. Now you are ready to be taken to the operation theatre.
In the operation theatre reception
The theatre nurse will receive you with all the papers and the X-rays ; reconfirming that everything is in order. You will also meet the anaesthetist who will explain what is to be done to keep you comfortable during the operation. After this, you will be taken to the operation room.
In the Operating Room
The anaesthetist will choose (with your consent ) either an injection in the back ( called spinal or regional anaesthesia ) or a full ( called General Anesthesia ) for the operation. Monitoring equipment which will measure your vital signs ( pulse rate, Blood pressure and respiration ) will be attached so that a continuous check of these parameters can be kept during the operation. You may choose to be awake during the operation if a spinal anaesthesia is administered or prefer to take a sleeping injection.
After anaesthesia, the leg will again will be thoroughly washed with an anti-septic solution and suitably prepared so that the operation can be performed. You will not get any pain and most people remark that they did not realise when the operation started or when it ended. Generally, the operation takes 1.5 hour to be completed although the time spent in the operating room is approximately 2.5 hours.
After the operation, there will be a bandage on the leg and the legs may feel numb for a few hours. You may have a tube inserted for drainage of urine and another tube in the thigh as an drainage for blood collection
After this , you will be shifted back to the ward.
Once the numbness of the legs is reduced, you would be able to move the leg relatively comfortably. You should start the following exercises as soon as possible:
In the lying down position, you should try to move your toes and ankle towards and away from you as shown. This helps in the circulation and reduces the likelihood of a clot formation.
Put a pillow underneath the heel as shown and practise tightening the thigh muscles. After tightening the thigh muscles, hold form a count of 1 to 10 and then relax. This should also be done at least 10 times every hour .
Once you are able to lift the leg in the air comfortably and your vital signs ( pulse, BP ) is ok, you will be asked to sit by the edge of the bed with both your knees dangling. Do not keep the leg tight at this juncture and the knee will be bent to around 70 degrees by its own weight.
Try to straighten the knee from the bent position by the edge of the bed as shown. ( If you pull the toes up, this becomes easier ) You should try to straighten the knee fully and hold to a count of 1 to 10 .
Do active knee extensions, 5 times every hour
These five exercises, ankle pumps, Quadriceps sets, SLR, sitting by the edge of the bed and Knee Extensions – form the major chunk of the exercises required after the surgery.
If these are properly done by 18 to 24 hours after the operation, you are ready to stand up and walk.. Some people may feel giddy or weak, and may not be able to walk properly. But most people are able to walk with support and help from the physiotherapist relatively comfortably after the operation
Discharge readiness
The number of days people stay in the Hospital following a Knee Replacement has been steadily reducing. Currently, most people are able to go home 2 days after the operation.
We can discharge the patient once we are sure that the patient will be able to manage at home. For this to occur, the patient should be able to sit up from a lying down position in bed, sit by the legs dangling by the side of the bed, get up form the bed, walk a bit and to be able to sit on a chair and to get up with support ( walker ). The pain should be under control and the dressing over the knee should be nice and dry. ( A few blood spots on the dressing are common ) Additionally, the patient should have used the washroom, should have passed urine comfortably, should have eaten and if there are other diseases such as diabetes, blood pressure etc . they should be under reasonable control. There should be enough home help and the patient and the relatives should also be willing to take the patient home.
Stair climbing is optional and my advice is that only if stair climbing is needed at home, it should be practised. Otherwise, it can be done later. It is not necessary to wait for a bowel motion before going home.
The aim in the first few days ( 1 to 3 ) is to make sure that the pain is well controlled , the knee keeps moving and to avoid swelling . The operation also is a form of injury to the knee and our body needs rest to recover.
We need only simple exercise with or without a physiotherapist. Exercise needs to be done for 5 to 10 minutes every waking hour with 2 hours of rest in the afternoon. The exercises in the first few days are the same that you have done in the Hospital.
Ankle pumps , Quads sets , SLR , sitting by edge of bed and dynamic quads ( Active Knee extension )
Keep a pillow under the heels of the legs. DO NOT KEEP A PILLOW UNDER THE KNEE. ( Elevation of the legs reduces swelling – Try to keep toes above the nose during the elevation of the leg )
Every hour – do 10 quadriceps sets – i.e. pushing the knee down on the bed with your own muscle. ( quadriceps ) In other words, you have to tighten the thigh muscles – and hold the thigh muscles tight for a count of 1 to 10. This is the basic exercise of the knee and you would have been shown this exercise before surgery and also in the Hospital before discharge.
Every hour, 5 times, you need to raise the operated and the unoperated leg, alternately, in the air keeping the knee as straight as possible. (And count from 1 to 5 )
How high to raise the leg? – You may raise the leg as high as comfortable.
Keeping the knee as straight as possible is extremely important and you should avoid bending the knee while lifting it. Do not raise both the legs together as this may strain your back unnecessarily.
You also need to bend the knee by the edge of the bed or whilst sitting on a chair, as much as the knee would bend comfortably and then make the knee straight again. It will help to pull the toes up whilst straightening the knee. You need to hold the knee for a count of 1 to 5. Avoid sitting on a low sofa or a stool. ( Preferably sit on a chair with handles so that you can take the support of your hands to get up .)
You need to walk for just a few minutes every hour. You may walk with support as comfortable and may move from one room to the other, walk in the corridor etc. Again, the stairs are optional.
The way the surgery is performed – You do not necessarily need a dedicated physiotherapist at home. (Interestingly, all the patients who were operated just before the lockdown due to Coronavirus – have also done equally well after the operation – despite no physiotherapist at home.)
Follow the rule of thirds
20 min every hour spend in exercise. (The other 40 min – rest )
Spend 1/3 of these 20 mins – in walking
1/3 – in knee bending and straightening exercises
1/3 in static knee exercise and ankle pumps.
You need to take normal diet ( not too oily or spicy ) preferably home-cooked food. It is normal to have a little loss of appetite after surgery. Most people find that falling asleep is difficult after surgery. This is why we always prescribe a sleeping tablet. You can take it if required.
The amount of pain is a little variable but is not as much as once thought. We would have prescribed pain killers to be taken by all and then extra pain killers which may be taken if the knee is extra painful. If you need to take extra pain killers, that does not mean that there is anything wrong. Pain is subjective and different people get different amounts of pain. Applying ice packs, elevating leg and not to overdo exercises help in relieving pain.
We would have applied a dressing on the wound. It is normal to see some skin discolouration and ecchymoses around the knee especially on the inner side. ( these would all settle over 4 to 6 weeks )
Essentially you would be doing the same things as in the first three days but more easily and with greater vigour and for greater time as tolerated . You may also add some hip exercises to your routine . The basic hip exercise is sideways leg raise.
You should lie on your side with the operated keg underneath and bent at 30 degrees. The other leg is kept straight. Now the unoperated leg is to be raised in the air by 30 degrees from the hip. Hold for a count of 1 to 5 and do 10 repetitions.
Now you lie down with the unoperated leg below and keep the operated leg straight. Now you can do 10 sideways leg raise of the operated leg.
Frequently Asked Questions
You may start going outside your home , in the compound etc. You may still avoid stairs unless necessary and avoid low seating . Sitting on the commode is generally OK
The need of physiotherapy has greatly reduced. However we advised to take help of physio for arounf 2 weeks Remember that a knee operation is also a form of injury to the knee and you primarily require rest. It is normal to have more pain on some days than others. You may take the extra painkillers as required. It is also normal to have some lack of sleep and some loss of appetite.
You will usually have had a follow-up visit around two weeks after surgery, where any concerns or questions can be addressed. At this stage, you should gradually increase your daily activities as tolerated and begin returning to normal routines rather than waiting for complete recovery. Try activities gently and progressively, stopping if you experience significant pain or discomfort.
Most patients are around 50% recovered by this time. Mild pain, swelling, heaviness, numbness, or a burning sensation around the knee is common and generally improves over the next 6–12 months. Continue focusing on fully straightening the knee and avoid placing a pillow underneath it. Many patients return to work during this period, walk comfortably for 20–30 minutes, and begin practising stair climbing as strength and confidence improve.
This is the time to gradually get back to “ normal “. This is not normal before the operation but “ normal “ before arthritis. the patients may exercise their knees, hips, walk and diet to become healthier. They may go out for walks, enjoy nature, see movies, dramas, visit religious places, shrines or whatever they fancy. They may go out of the city as well.
They can continue the gentle exercises for the knees and the hips for better toning of the muscles and better gait.
Obviously, each patient is different and each patient’s requirements are also different. The aim here is for the patient to get back to their desired quality of life. However, it is still not uncommon for patients to complain of pain, especially at night. If the patient is able to walk properly and bend the knee well then probably there is nothing wrong. However, if there is the consistent complaint of pain, investigations including aspiration of the knee ( inserting a needle in the knee to withdraw some fluid ) may be required to rule out infection.
The modern knee Replacements are designed for long term function for 20 years or even more. However, as in all things mechanical some maintenance is required. At least once in 3 years, the operated Knee should be X-rayed to ensure that the replaced joint is looking OK on the x-rays. As it is a replaced knee, any problem with the knee will initially manifest with X-rays, even before any symptoms develop. Apart from this, the knee is to be used but not to be abused. By that is meant, that the knee is to be used judiciously.
he complications can be General ( affecting the whole body ) or local ( related to the Knee )
The General complications can be a heart attack, embolism, stroke etc. Depending upon the severity, even deaths have been reported after a Knee Replacement. Obviously, as we screen the patients well the likelihood of this kind of a complication is very low.
The local complications can be infection, instability, loosening, fracture, dislocation, complications related to the knee cap, muscle-tendon rupture etc. Again the likelihood of these complications is very low in experienced hands. .
You would be advised to follow up at 2 weeks, 6 weeks, 3 months, at a year and then every 3 years from the operation. Obviously, if there is need you can follow up at any time. It is important to maintain optimum weight and to have a healthy lifestyle. Also, it is advised to have the knee Xrayed once in 3 years. If an actual physical follow up is not possible, a virtual follow up can also be done.
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