Total Knee Replacement Surgery: A First-Hand Experience
When Do You Need a New Knee?
If you are having daily range-of-motion issues; reduced mobility; pain on walking or even when at rest, it’s time to consult your doctor. For the initial visit, you will probably see your primary general doctor, who will refer you to an orthopedist. That doctor will send you for diagnostic images, which may include x-rays and possibly an MRI of the affected knee. These will show him how far advanced your condition is, and recommend for or against a replacement surgery. Ultimately however, the decision of whether to undergo the surgery or just deal with things as they are is up to you.
The surgery itself comes in two options: full or partial replacement. Which is right for you will be determined by your surgeon.
Was the Cause an Injury, or Just “Wear and Tear?”
Over time, as we age, our joints become less flexible, and we are subject to arthritis and its various discomforts. This can damage the joint to the point where it no longer functions well and a replacement would help.
There is also the possibility that the knee was injured suddenly and too severely to repair, and a replacement is in order. Again, in either case, these diagnoses are made by the orthopedist in consultation with you, the patient.
Speaking from personal experience, I would highly advise that in the case of an injury, you go for it, and the sooner the better if possible. Because I had no medical coverage at all for over 10 years after my injury (which began as a torn meniscus--a much easier repair), I grew progressively worse, until arthritis also set in, and I was out of options.
Indeed, I never saw a doctor when the injury happened--years later, I became eligible for free “medical care” from the county; they are the ones who diagnosed the injury, but then blew me off about treating it! Once I aged enough to be eligible for Medicare, I was able to get the repair done--but of course, the problem was of such long-standing that my rehabilitation period was longer than it otherwise might have been.
Once your surgery is scheduled, depending upon your health care provider, you may or may not be sent to a class to learn all the things that will happen in the hospital and afterwards at home. This includes anesthesia options; what to expect in the hospital environment; physical therapy in-hospital and after; whether or not you have adequate help at home during recovery, and so forth.
You'll be sent for blood work, and possibly an EKG to make sure your heart is able to withstand the anesthetic and the surgery.
You will also be strongly encouraged to have any necessary dental work completed prior to your surgery. This is because any infection present in your mouth can possibly migrate through the bloodstream and into the surgical site. An infection there would be very bad news indeed, and could jeopardize the entire procedure.
If there is a lag of a month or more before your surgery, you may be given pre-surgical exercises to help strengthen the surrounding muscles prior to the operation. This will help in the recovery period. (I was not so lucky--I got in on a cancellation, and had only about a week's notice before my surgery.)
What to Expect
Once you are checked in on the day of the operation, you’ll be poked and prodded with various preparatory things…ranging from blood pressure cuffs, thermometers and placement of the IV (Intravenous) catheter for administration of first, the anesthesia, then fluids and pain control medications afterwards.
Most likely, you’ll see your surgeon briefly, and he (or she) may write on your leg to mark the correct one--a very important thing! The anesthesiologist will also see you, and explain that procedure. It can all be a little confusing and intimidating, and you will no doubt be nervous anyway. That’s to be expected.
However, when they wheel you off to the operating room, that’s the last thing you’ll remember until you wake up in the recovery area. The surgery takes between 2 and 3 hours to perform, but those are the fastest 2 to 3 hours you’ll ever pass, because you “weren't even there!”
Anesthesia Options You May be Offered:
- General anesthetic, in which you are in a very deep sleep, completely unaware of anything that is going on.
- Spinal anesthetic, which is injected between the vertebrae, and causes you to be totally numb from the waist down. You will also be given a sedative to calm you, so while you may be nominally "still awake," you will feel nothing, and probably fall asleep anyway.
- Femoral nerve block, which is injected into the groin area, and numbs just the operative leg. Again, you'll probably be given a sedative to calm you and you may fall asleep.
Disadvantages to any of These Were Explained as Follows:
- General anesthetic is harder on the body, including the heart and lungs, so it will depend upon your general state of health of those organs whether this is offered. I was also told that the post-op pain is worse with a general than with a spinal.
- Spinal anesthetic can be risky--any time you are introducing anything into the spine there is a possibility of nerve damage, infection, or of the medication going to the wrong location, if the placement is off.
- Femoral block holds the possible after-effect of "foot drop," in which you may find it hard to pick up that foot without your toes dragging. If this happens, you will be given a leg brace to help.
Naturally, all of the disadvantages, cautions and warnings are given multiple times, and in rather exaggerated fashion to please the legal department...
What Are They Doing to Me?
I was still awake upon arrival in the operating room. Even though I was somewhat sedated, I was sufficiently awake to glance around and notice an array of things that looked like carpentry tools! But, I didn't have much time to think about that, because as soon as I was on the operating table, they put on the mask and I was out within a couple of seconds.
Whether the knee replacement is full or partial, the general procedure is very similar. After making the incision to expose the dysfunctional joint, the surgeon will need to remove the damaged parts and shape the ends of the bone to fit the new joint. This includes drilling holes into both the femur (thigh bone) and the tibia (the larger of the two bones in the lower leg) to accept the shafts of the prosthetic so that it will be stable. Depending on your surgeon and the type of replacement joint they are using, it will also likely be cemented in place with a special cement.
It sounds grisly when you think about it, but apparently, there are no internal nerves in the bone. You don’t feel that once you are awake. Sure, there is pain at the incision, and the nerves and muscles will be complaining from having been shuffled around to make room for the doctor to work, but there is no pain at all within the bones.
The Implant in X-Ray View, and Post-Op Splint
It’s Over, and You’re Awake. Now What?
Naturally, your waking-up process will be very slow--you’ll start to wake up, but it will be just too much effort to keep your eyes open at first; you’re still very groggy from the anesthetic. As it wears off, though, you’ll gradually awaken fully.
Then you start to experience post-operative pain. For the most part, that isn't horrible, as today’s hospitals do a pretty good job of keeping you medicated to control your pain to tolerable levels. That said, there will be some pain, and you will at first be unable to move that leg unassisted. The down side of the pain control meds you get via IV is that, while they kick in much faster than pill versions, they tend to cause nausea in many people. Don’t worry--there’s yet another medication to help with that side effect!
You may find that your leg, in addition to the bandages, has been encased in a removable splint of sorts--this is to prevent premature bending or moving of the leg while you are asleep. In my case, it was removed early enough that the photo at right is all the "memory" I have of this--I don't recall having it on.
CPM Machine in Use
A CPM Machine May Be Used
You may find that you have been scheduled to have your repaired leg strapped into something resembling an old torture device, called a “CPM (Continuous Passive Motion) machine.” Be thankful. It keeps the joint from stiffening up, and makes getting up and your post-op physical therapy easier in the long run.
This device is a framework with a motor and hydraulic shaft and piston sliding on a track under a cloth covered cradle that supports your lower leg. As it runs, it gently pulls and pushes your leg from bent to extended in a repetitive cycle. I was put into it for two hours twice a day.
Inquire about having one rented for use when you get home; if the doctor writes a prescription as “medically necessary,” most insurance, including Medicare, will pay for it. You must convince your doctor that YOU need the gizmo, and get him to write that prescription.
I neglected to mention this to my doctor, as I did not realize just how helpful it would be. You WILL need strong help at home to use it, though--the thing is heavy--it always took two nurses to lift it on and off the bed--even guys.
Getting Up and About
The leg will be all bandaged and wrapped at first--you won’t be able to see anything of the surgical site. For me, this was just fine--I tend to get queasy rather easily. There are many variables between doctors and hospitals about how soon you will be getting out of bed and walking around. For me, it was the next morning after the surgery. I was so scared I wouldn't be able to stand the pain of bearing weight on that leg. I found, however, that thanks to the meds, it was no worse than the pain I had been in prior to the surgery--and I’m about the world’s biggest wuss, so if I could handle it, anyone can!
At first, you’ll most likely be using a walker to navigate. Your balance will be off, and you cannot walk unassisted, either with a person helping, or with an assistive device such as a walker or crutches. You will be taught how to use the walker, and how to get yourself in and out of bed; to the bathroom; and for short walks up and down the hall. You will be asked about any stairs you may have at home, and taught how to negotiate them safely.
You will probably also have your first physical therapy while still in the hospital--this will consist of ‘range of motion’ exercises, and a lot of ankle rotations to encourage the circulation in your legs and feet.
Do not be surprised when you are sent home only two days, or at most three, after your surgery. These days, hospital stays are dictated more by what insurance or Medicare is willing to pay for than what is truly in the best interests of the patients.
Even so, it is better to try to get back to a semi-normal routine sooner than later. In the “bad old days” when people were kept in the hospital and in bed for a week or two following a major surgery, recovery time was actually longer, because of the lost muscle tone while lounging in bed day and night. Also, complications such as blood clots were more common, because of the blood tending to “pool” in the lower body areas where you are resting in bed.
Your Job at Home
Once you are home again, it’s not over. The hard part lies ahead. Your age and prior mobility at the time of surgery are prime factors that will contribute to how fast you are able to recover, and how hard or easy your physical therapy will be. Another factor is how long it was between the onset of the problem and the surgery. The longer you lived with it, as in my case, the tougher it will be on the other side.
I found my physical therapy a rather painful challenge, but it had to be done and worked through if the surgery was not to have been in vain.
Most likely, you’ll be scheduled for physical therapy appointments once or twice a week at your clinic or hospital. During that time, the therapist will evaluate your range of motion and balance progress, and assign either new exercises or additional repetitions of existing ones to help you build strength. Remember, it’s the muscles of the thigh and lower leg that support the knee joint and allow it to work smoothly, and those muscles must be re-trained. Also, the supporting ligaments must be re-stretched to allow your full range of motion.
Generally speaking, however, the following table of expected progress is given:
- 3-6 weeks using walker
- 3-6 weeks using crutches or cane
- 6 weeks or more before trying to drive
- 3-4 months to a year to return to pre-surgical/pre-disability activities and range of motion, depending on how active your lifestyle was prior to surgery
If you are sent to see a physical therapist at various intervals, you will most likely be using equipment familiar to anyone who has been to a fitness club. There are upright stationary cycles; recumbent cycles, weight machines, parallel bars, mirrors so you can check your progress with the exercise, balance balls, and the like.
For knee surgery, you will probably not be put on the weight machines, but on the bikes and the parallel bars. There are also tables on which you will do exercises while lying down. Additionally, you may be given resistance bands, which are tied off to something heavy, and placed around your leg or ankle, to make a range of motion exercise more of a challenge. (These are items not usually found outside of a medical "gym.")
You may see the therapist once or twice a week, depending on your situation, condition and your doctor's recommendations. You must, however, continue to do all the exercises you have been given at home, on a daily basis, for full recovery.
Some Examples of Exercises You May Be Given
All in all, the entire process was not as bad as I had feared. However, as I said previously, in my case, I was recovering not just from the surgery, but also from a dozen years of a prior untreated injury.
My physical therapy was rather painful and challenging, and I did not recover as fast as someone who was seen in a much more timely fashion. That's behind me now, though, and I simply focus on moving forward, for I cannot change the past.
Coward that I am, I managed to handle it, so I would definitely recommend this surgery if your doctor says you need it. Modern medicine is amazing; I'm just wishing for the Star-Trek type of non-invasive repairs, but I know that's not going to happen in my lifetime.
Thank you for reading. I hope this article was helpful to you if you are facing the decision for having a knee replacement.
The decision to have or not have this surgery is up to you, the patient, and not the doctor alone. Be vigilant about your rights as the owner of the body inside of which you live.
Have You Ever Had a Knee Replacement?
Months Later—an Update
So, what happens months down the road when your recovery progress has been interrupted, or not gone as well as you'd hoped? In my case, my husband's health deteriorated, and as his sole caretaker, I was sidetracked from keeping up with my own therapy and exercises as well as would have been preferred.
There are a few options available, most of which involve some pain. How much pain depends on your own level of pain tolerance. For me, the latter is near zero, so the pain scale was pretty high.
Physical therapy will continue, but there are other things added to the mix.
The "Torture Chamber"
Well, not truly torture devices, for they are not designed to be such; but they surely look like something out of a dungeon.
I was given a knee splint, complete with straps and a ratchet device for cranking the knee either to a more bent or more straight position. This was supposed to be done for half an hour three times a day. You cannot walk or move about while wearing this device.
The device was very complex, and required several visits from the fitter to get it to where it was even usable. It is not comfortable at all with the best fit.
Again, my husband's health continued to be unstable, and this is not a device you can use very well on the go, or sitting in a hospital emergency room. So, that did not work out well, either.
Back to the O.R.
That's right. With the apparent failure of the fancy splint device, it was back to the operating room. No incisions this time, but they do put you under anesthesia, and force the knee to bend and straighten as it should.
Yes, it's painful afterwards, as what they were doing was ripping and tearing scar tissue, known as "adhesions" that develop after an injury or surgery. So, back to the ice packs, and more physical therapy.
The first two weeks after this procedure is critical. But there is an additional 'catch.' I was told by the doctor that the range of motion of the knee prior to surgery is a fairly good indicator of the final outcome afterwards.
Oh, dear. My range of motion was pretty restricted already, and since I got into the surgery on a cancellation with only a week's notice, I had no time for preparatory physical therapy or strengthening exercises to build up the muscles supporting the knee, to assist in recovery.
At this point, I am beginning week two, and working very hard to overcome the setbacks I've had. At times, the exercises reduce me to tears, and are sometimes more painful than was childbirth.
Nonetheless, I persevere, for I do so want to return to riding my bike and get back on my rollerblades!
Update: A Year Later
Well, as of this month, April of 2014, it has been a year since the surgery. Is the knee perfect? No. It probably never will be as good as the original knee prior to the injury.
However, it is a thousand times better than it was before the operation. I can now lift my knee up onto the opposite leg to tie my shoe or dry my feet; I can get down on my knees to do things (but padding is appreciated); I can walk without cane or walker, back at my normal speed; I can ride my bike, and return to my karate classes. I look forward to returning to my in-line skating just as soon as the weather warms a teeny bit more.
There is still a little bit of swelling, which I was told may never entirely go away; there is still a slight tendency for achiness in cold weather; and to stiffen up a bit if sitting for too long in one position. But, that also all goes along with getting older, knee replacement or not.
All in all, I cannot complain, and am very happy with the outcome.
Update—Looking Back 2.5 Years
The physical therapy is extremely important, and the exercises must be done daily.
Unfortunately, just as I came out of the hospital, my husband started in with a very bad couple of years with his heart condition, as briefly mentioned earlier. He was bouncing in and out of the hospital and the emergency room like it was the thing to do.
Sitting there at his bedside, as well as trying to manage the household with no help before I really should have been, I was unable to do my exercises as often as I should have, and it delayed my recovery. I got 'stuck' at a certain point, unable to bend my knee very far past the pre-surgery point.
The 'torture devices' did not help, and were very complicated. I was unable to get any results from those things.
The solution for this, was to put me back under anesthesia, and force the knee to bend to where it should have been by that point. This was an out-patient procedure.
It was vital for me to go back to the physical therapy department the very next day, and get back on track with my exercises. At this point, two and a half years later, the knee bends much better, but I am still unable to fold it completely under me and bear weight, as when one sits back on their heels. The doctor told me I might be able to work it back to that point, but at this stage of my life, I'm not sure it's worth the painful exercises that would take. (Again, I'm a wuss.)
(Below is the photo the doctor took during the manual manipulation procedure, and gave to me for reference. Sorry the photo quality is not great; it was a small photo, scanned in.)
© 2013 Liz Elias