LIFE   WITH  A TOTAL  KNEE

CONTENTS:

precautions

problems you may encounter  home

pain in the replaced knee joint

everyday activities

do and don't

driving

range of motion in your new knee joint

walking aid devices

1

Precautions

Your surgeon and your physical therapist will usually provide you with a list of do and don’t  to remember with your new knee. More "strict" precautions apply for the first 6 -12 weeks postoperatively. These precautions vary according to the operation method, prosthesis type, and the surgeon. Ask your surgeon and your physiotherapist for a written list of precautions and when they can be lifted. Be sure to follow all precautions you learned in the hospital.

This applies to the use of crutches, loading your new knee joint,  performing of gymnastics, and other issues.

2

Problems you may encounter home:

• Excessive swelling of your operated leg and foot. It usually develops during the first few weeks after surgery. The collected blood in the tissues around the knee will sink and the swelling may take a bluish color.

Note: excessive swelling in the leg and foot, associated with pain in the calf  may be a sign of vein clots (deep vein thrombosis). Contact immediately your doctor.

The collected blood (hematoma) is, however,  an excellent nourishment for bacteria. Your surgeon will decide how to treat this disturbance of the operative wound healing.

There is always a risk that bacteria may  be "towed" into  the collected blood and start postoperative infection.  Be careful not to damage the skin around the operative wound, do use only shower during the first postoperative weeks.

• If the quantity of the collected blood in the soft tissues around the total knee is large, it may exercise  pressure on the nerves and muscles in the thigh and lower leg. This condition (compartment syndrome) causes intensive pain.

  When such large hematoma develops it is thus necessary to reopen the operative wound and evacuate the collected blood.  Your surgeon will decide how to treat this disturbance of the operative wound healing.

• The surgeons often put pneumatic tourniquet around the thigh to minimize bleeding during the operation. The pressure from the tourniquet may cause transient aching in the thigh musculature.

• Elevated temperature (over 38 C or 100 F) may be a sign of impeding infection. Take your temperature twice a day for a month after surgery, if not prescribed otherwise. If you get repeated readings over 38 C (100 F) contact your doctor.

• Increased quantity of joint liquid - swollen knee. This may appear after excessive strain put on knee. It is then a useful warning sign telling you to reduce your activities. 

If the the increased quantity of liquid is persistent, you should contact your doctor;  it may be heralding increased wear of polyethylene or another complication.

• Chest pain, a cough, or shortness of breath may herald embolism. This is always a serious sign. Contact your doctor immediately.

3

Pain in the replaced knee joint

 

Studies demonstrate that total knee replacement is very efficient to relieve pain, as the following Table demonstrates.

The Table shows the percentage of patients with none or only "some" pain in their new total knees during different  everyday activities.

Note, however, that all these patients were interviewed more than two years after their total knee  operation.

In another study, however, about 17 % of all patients have had moderate or severe pain eight years after the total knee replacement. The important observation is that the percentage of patients with knee pain after total knee replacement does not increase as the time since surgery goes.

In contrast to total hip replacement, the knee pain disappears only slowly after the operation. Six weeks after the total knee replacement patients have still had "considerable" pain in their knees. (Aarons 1996)

Be patient, it takes often one year before you will experience the full benefit of the total knee surgery.

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4

Everyday activities

Studies also  demonstrate that up to 90 % of the patients operated on with total knee replacement

are generally satisfied with pain relief - but

walk more slowly

have reduced muscle strength

do not achieve comparable overall physical health and mobility as people in the general population. (Jones 2001)

Some activities are more difficult than others  to carry out after the total knee replacement.

The following Table shows the percentage of patients who have "a lot" / severe difficulties to carry out the following activities.

Conclusions: skip bathtub, use shower

                     do live on one level apartment, skip stairs

(Hawker 1998)

5

Do and don't

Here are some of the most common general precautions.

• Avoid falls. Don’t move in environments where you can stumble and fall. A well-lit and easy path from the bed to the bathroom is essential for  the night visits of the bathroom.

• Never squat

• Do use high stools and chairs with arms
• Don't use shoes with shoelaces
• Use shower instead of bath tube.

• Observe the scar and the skin in front of your operated knee. Avoid damage to the skin during exercises. Avoid exercises that excessively stretch the skin and the  scar.
• Do cut back on your exercises if your muscles begin to ache, but don’t stop doing them entirely

• If possible, exercise in pool - the buoying effect of water facilitates movements in your joints. The wound must be healed then.
• Do use ice to reduce pain and swelling, but don’t apply ice directly on the skin
• Use pain medication when necessary, e.g. before the exercises or at night.
• Exercise regularly
• Keep your body weight under control. Excess weight increases stresses on your total knee joint and can cause failure of the joint prosthesis.
• If you develop a bacterial infection elsewhere in your body (for example bladder infection, boils, infected cuts, dental abscess) you should consult your doctor and have him to treat the infection promptly. The bacteria can otherwise travel via your bloodstream to your total knee and cause infection.
• Avoid open wounds in your legs - open wounds may become a portal for bacteria to enter your new knee joint.
• Dental work can push "innocent" bacteria from your mouth cavity into your bloodstream and cause an infection in your knee joint replacement. Always notify your dentist or any other physician who treats you that you have an artificial joint. The prophylactic antibiotic use in connection with dental work varies from surgeon to surgeon (and the dentist). Ask your surgeon for advice.
• Also instrumental examination of lung (bronchoscopy), bladder (cystoscopy), or bowel (colonoscopy) pushes bacteria in your bloodstream and should be also covered by antibiotics. Ask your surgeon for advice.
• Studies indicate that the risk of an artificial joint infection by bacteria travelling via a bloodstream is at its highest during the first two years after the operation. (AAOS, http://orthoinfo.aaos.org)

Viral infections, such as colds and  sore throats, do not endanger your total joints. Prophylactic antibiotics should not be used in these cases.

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6

Driving

Driving is not likely to injure your total knee prosthesis, but you may not be able to operate the car as well as needed to prevent an accident. Usually, it  takes 8 weeks before you develop sufficient control of your new knee joint. During this time, or until you have full control of your total knee, you should not drive the car. Ask always your doctor.

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7

Range of motion in your new knee joint

Range of motion in a normal knee joint is from full extension (0 degrees) to  about 140 degrees of flexion. For a healthy person

walking on ground level requires flexion from 5 to 65 degrees

rising from low  chair requires flexion to 105 degrees

descending  stairs requires 100 degrees of flexion

The activities that demands the largest flexion is   tying shoes (110 degrees) and getting out of  bath  tube ( 130 degrees)

In patients with osteoarthritic knees the knee excursions with these activities are considerably smaller.  (Walker 2001)

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How much will  you extend and flex your new total knee joint?

The goal is to  at least  80 degrees flexion in your total knee at the discharge from the hospital

Studies show that restricted total knee joint flexion is  rare in patients who  achieved at least 80 degrees of flexion in their new knee  at discharge from the hospital.

 

The range of flexion in your new knee joint will increase successively during the rehabilitation period.

This is a long term process that takes about one year to accomplish, although the biggest gain in motion is achieved during the first three postoperative months. The gain of the flexion is slightly greater in patients operated on for osteoarthritis than in patient with rheumatoid arthritis disease.

Actually, there are few everyday activities that demand knee flexion beyond 105 degrees. This may be the reason why some  total knee patients have less knee flexion after the surgery then before the surgery. (Schurman  1985)

Closer study showed that the patients who have had flexion more than 100 degrees before the operation  lost some flexion in their new total knees

whereas the patients who have had flexion less than 100 degrees before the operation  gained some flexion in their new total knees.

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The range of the extension in the total knee joint is destined at the operation moment:

the surgeon must correct all obstacles that hinder full passive extension in the knee. The passive range of extension will not improve during the postoperative rehabilitation, only the muscle force that extends (stretches) the new knee joint will.

 

Mean muscle strength (kg) to knee extension after total knee replacement

	Mean Muscle strength /extension (kg)
Before surgery	57
3 months after surgery	55
6 months after surgery	67

As the Table demonstrates, the training of the muscles that extend the knee joint is a tedious process taking several months. (Lorentzen 1999)

If  you will not succeed to get a strong   quadriceps muscle  (the muscle which extends the knee joint),  you will not be able to keep the total  knee straight during everyday activities. This defect may result in difficult instability of the limb. This defect is called  "extension lag".

 

Conclusion:

work hard to increase the motion of your new knee joint

be not disappointed if you will not attain exactly the preoperative range of motion

the range of motion in your new knee will depend on the range of motion in the knee joint before the surgery. The worse the preoperative range of motion  the smaller are the chances that you will achieve   a "normal" range of motion in your new knee joint.

Your new knee should be stronger, less painful,  and getting larger range of movement each day. If not, contact your surgeon.

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8

Walking  aid devices

The three most commonly used walking aid devices are

crutches (axillary or elbow crutches),

canes (walking sticks),

walkers.

The purpose of  using walking aid devices in patients with total knee is  to :

diminish the stresses on the total knee,

keep the soft tissues at rest in the postoperative period

help to keep the balance for patient with weak musculature or with balance problems

The surgeon who  prescribes your walking aid should take into account  your general  condition so that the you will get the   correct device.

This may include individually adapted / molded  handles of crutches for patients with hand deformities, choice of proper length of the crutches.

You should also receive  a  thorough instruction on proper use of walking aids; the physical therapist usually conducts the teaching and together with a prosthetic technician they adapt the walking aid device to your needs.

As soon as possible switch to walking with cane. Walking with crutches for too long  will force you to use  bad walking method.

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Some common problems with the use of walking aid devices  are:

falling - the crutches slip   on slippery surface. Prevention: remove small/ throw rugs, avoid slippery surfaces, equip crutches with pointed nail ends for walk on  snowy / icy surfaces if you must.

carpal tunnel syndrome - the damage of the median nerve in the wrist area. Usually caused by keeping the hand bent upward in the writ for long periods. (Werner 1989)

The patient feels  numbing  pain in the thumb and in the index and middle finger, he / she may loose sensitivity in the hand and even loose function in the muscles of the thumb.

Prevention: don't use the crutches for long periods, use special wrist braces. If you develop numbness in your hands after using crutches ask your doctor for help.

Numbness and skin  excoriation around the axillary region in the axillary crutches. Prevention : don't use axillary crutches anyway, they  produce a clumsy and abnormal method of walking (Charnley)

Skin damage and  localized numbness in palm - caused by pressure from the crutch handle. Prevention: switch to cane (walking stick) if possible, otherwise ask your PT for a crutch with individually custom made wide handle. Such crutches distribute loads over a greater surface, producing less local pressure.

 

References

Aarons et al.  J Bone Joint Surg-Br, 1996;78-B: 555-8

Hawker G et al.  J Bone Joint Surg-Am, 1998;80-A: 163- 73

Jones C. et al. Arch Intern Med 2001;161: 454-60

Schurman G et al.  J Bone Joint Surg - Am: 1985, 67-A:1006-1009)

Lorentzen O et al.  Acta Orthop Scand;70:176 -9

Walker J Bone Joint Surg-Br, 2001;83-B:195-8

Werner et al :  Arch Phys Med Rehabil 1989;70: 464-7

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