Comprehensive patient guide for before, during and after knee replacement surgery.
At UF Health Orthopaedic Surgery in Jacksonville, our premier surgery team will take great care of you. Our goal is to provide the most up-to-date surgical and reconstructive techniques and assist you throughout your recovery so you can achieve your best outcomes.
Knee replacement surgery — also known as knee arthroplasty — can help relieve pain and restore function for patients with severe arthritis. There are two types of knee arthroplasty: total and partial. Patients typically undergo surgery after nonoperative treatments have failed to provide relief from arthritic symptoms. Surgeons have performed knee replacements for over three decades generally with excellent results; most reports have 10-year success rates in excess of 90 percent.
Your painful knee will be replaced with an artificial knee joint called a prosthesis. Your surgeon will choose the best type for you. The prosthesis is designed to work in the same way as your natural knee to give you smooth, pain-free movement. A prosthesis will be inserted to “replace” your deteriorated joint areas and is custom-fit to you by your surgeon.
Most surgeries go smoothly; however, there are two serious complications that are most concerning — infection and blood clots. Antibiotics and blood thinners are used during and after surgery to reduce or prevent the risk of these complications. Special precautions are also taken in the operating room.
Preparing for knee replacement surgery
Gather needed medical information
When your surgery was scheduled, you received a packet of information from UF Health Jacksonville. You may be required to obtain a clearance letter from your family doctor or internist. The hospital will need all lab tests, EKGs, X-rays and a clearance letter before your pre-op appointment. Your surgeon may request medical clearance prior to surgery from other specialists, such as a cardiologist, pulmonologist or nephrologist.
Gather medication information
You should bring with you all your medications or a list of all medications with dosage and frequency instructions to your pre-op appointment. This includes over-the-counter and prescription medications. The correct medication and dosages are important to maintain your health throughout your hospital stay.
Get a head start on learning your post-op exercises
Exercising your knee is a vital part of recovery, so it’s a good idea to prepare by attending a joint replacement education class or watching the exercise videos on the UF Health website. (Is there a link?) You can do these exercises before your surgery if you are able, and throughout your hospital stay as well, independent of your therapy sessions.
Contact your insurance company
Outpatient physical therapy, or PT, will be discussed with you and arranged by the case manager prior to surgery. You can expect to need at least 16 sessions of physical therapy after surgery. This therapy is designed to help you regain mobility and enjoy the activities you used to do and is usually ordered by your doctor for two or three appointments a week. The length of time required for therapy varies with each patient. Most insurances cover this, although you may have limited choices in your service area. Call the number on the back of your insurance card to determine coverage, including the facility and copay. This should be done one month before surgery. UF Health has four outpatient locations: downtown Jacksonville, North Jacksonville, the Southside and Yulee.
Plan for a ride home
You cannot drive yourself home after surgery. Before you are admitted to the hospital, arrange for someone to drive you home. And when packing clothes for your discharge, it is best to bring loose-fitting clothes that can easily be applied over your knee bracing.
You may be scheduled for pre-admission testing
Prior to your surgery date, you may be scheduled to come to pre-admission testing, also called PAT. At this time, a complete history and physical will be done to ensure you are in the best possible condition for surgery. A chest X-ray and EKG may be performed. Bloodwork may also be done. Not all patients require PAT. Your surgical coordinator will notify you if PAT is ordered by the surgeon.
What can I expect the day of surgery?
Your arrival procedure
You will not have had any food or water before surgery. You will be taken to an area called pre-op holding or to the block room. Your family will be shown where the waiting room is located. This is where the doctor will find them after your surgery.
Meet with the anesthesiologist
You will see an anesthesiologist before your surgery, who will review your medical history, perform a brief physical exam and discuss your options for anesthesia.
- General anesthesia will make you unconscious and unable to feel pain during your procedure. It is produced by a combination of drugs and gases.
- Spinal anesthesia uses a small needle to inject an anesthetic solution into your back. This medication should take away all pain sensation and movement from the abdomen down to your toes. You also will be sedated so that you are comfortable and unaware of your surroundings.
- Epidural anesthesia uses a needle to inject the medication into your lower back. With the epidural, a small catheter is placed through the epidural needle to deliver medication while in surgery and for a few days after surgery.
- Peripheral nerve block provides a safe, comfortable way to reduce pain during and after surgery. The nerve block delivers numbing medicine near the nerve and temporarily reduces messages from the nerve to your brain. A very thin catheter connected to an infusion pump will provide numbing medicine to your knee and will be kept in place during your stay. This form of medication is managed by the anesthesia pain team.
- Femoral nerve blocks are used for surgery on the thigh and knee, and the block is administered just before surgery. The block numbs the nerve that transmits signals from much of the front and sides of the thigh and knee. A separate block of the sciatic nerve is usually required to fully numb the back of the thigh and lower leg. If continuous infusion is planned for long-term pain control, a small catheter will be inserted and connected to a small portable pump. Numbness lasts up to 12 hours with a single dose or until the continuous infusion catheter is removed. Following surgery, you’ll need to take special care of your leg until sensation fully returns. A side effect of the femoral nerve pain block is the temporary loss of quadriceps muscle control. After surgery, you will be fitted with a knee brace to provide support so that you can stand with your walker for the first few days after surgery.
Length of surgery
You will be in surgery for about three hours, including preoperative prep time and transition to the postoperative care unit. You will have an IV in place during your hospital stay.
You will remain in the postoperative care unit until your room is ready for your overnight stay. Most patients stay in the hospital for one night, but you may be a candidate to go home the same day of surgery. Your surgeon will decide the timing of your discharge based on your fitness level, level of pain and ability to move after surgery. If you are going home the same day of your surgery, you will remain in post-op until you are discharged. A therapist and nursing staff will work with you in the recovery room to get you ready to go home.
Swelling and blood clot prevention
Patients who have knee surgery are at risk for developing blood clots that can be dangerous if they break away and travel to the lungs. Although blood clots are rare, there are several things you can do to decrease the chances of blood clots forming. When you are lying in bed after surgery, it is very important that you begin leg exercises. These can be done by pressing the backs of both knees into the bed, tightening your calf and thigh muscles and moving your ankles up and down. Your physical therapist can show you how to do these exercises properly. It also is important that you get out of bed and sit in a chair, as well as start walking as soon as possible with assistance. As soon as you are able, you will begin circulation exercises such as ankle pumps, quad sets and gluteal sets. Cooling units, ice packs and elevation will help control swelling.
- You may be instructed to wear compression stockings to help decrease swelling in both your legs. They will be placed on your legs right after surgery, and you will need to wear them the entire time you are in the hospital. You will only wear them during the day and remove them before bedtime. In order for the stockings to help, it is important they fit properly. They should feel a little tight, yet smooth and without wrinkles or creases. They should not be cut or rolled down. Wear them after you go home until there is no tendency to swell, usually around 10 to 30 days. Your surgeon will tell you how long to wear the compression stockings.
- In the hospital, you will also wear a sequential compression device to help circulate the blood in your legs. Sequential compression devices are cloth sleeves attached to a pump that hooks onto the end of your bed. Air is pumped into the sleeve through hoses and then released.
- You will also receive medications to help prevent blood clots, especially if you have had blood clots in the past. Your doctor will give you instructions on taking these medications. Coumadin is one drug that may be prescribed. If you are taking Coumadin, it is important that your blood is checked every day while in the hospital until the desired blood lab value is obtained. If your doctor has you continue to take Coumadin after you go home, you will need to have your blood values checked once or twice a week. These tests will be scheduled for you before your discharge from the hospital. In addition, you will receive dietary instructions from the dietitian, as some foods may affect your Coumadin level.
- Aspirin, heparin, Lovenox (enoxaparin), Eliquis (apixaban) and Xarelto (rivaroxaban) are other drugs that help prevent blood clots. If your doctor orders one of these drugs, you will receive instructions.
- Signs and symptoms of blood clots include heat and redness in the calf muscle area, and pain in your lower legs or swelling not relieved by lying down and putting your legs up. Notify your doctor immediately if you have any of these symptoms. If you become short of breath or develop chest pain, call 911 or go to the emergency room. It is important to follow up with your doctor as soon as possible upon returning home.
Prevention of pneumonia
Coughing and deep breathing exercises are very important to help prevent pneumonia. Your nurses will ask you to take long, deep breaths several times each hour and to cough up any mucus. You will be taught to use a device called an incentive spirometer that will help you with deep breathing exercises. A nurse will show you how to use this before surgery or right after surgery. To help prevent lung problems, remember to stay active with the assistance of a nurse.
If you smoke, quitting before surgery will help your recovery and decrease your chances of getting pneumonia. Smoking is not allowed while you are in the hospital.
Robert Jones dressing
After knee surgery, your physician may request a special dressing be placed on your leg. For some physicians, the Robert Jones dressing is used postoperatively for one day to apply gentle pressure to the limb to help control swelling and bleeding and is usually removed within 24 hours after surgery. The dressing will limit how much you are able to bend your knee; however, you can work on straightening and lifting the leg. You should also do the range-of-motion exercises your therapist showed you to the extent you are able.
Care of your incision
Your surgeon will determine if your incision will be closed with metal clips called staples or with a special type of glue. You will have a large, bulky dressing, or your knee will be wrapped from your toes to your upper thigh the day of surgery and the first day after surgery. The bulky dressing will be removed the following day and a lighter gauze dressing will be applied. We will watch for any signs of bleeding or infection and keep your incision dry by changing the dressing as needed.
- If you have a Hemovac/Autovac drain, it will be removed the first day after your surgery. You may feel a brief burning sensation when the drain is pulled out. To prevent infection, you will receive antibiotics through your IV as long as the drain is in place.
- Your dressing should be changed whenever it has drainage on it. The nurse will show your family or caregiver how to change the dressing before you leave the hospital. Hands should be washed each time before changing the dressing. Avoid touching your incision until it is healed.
- Staples are removed 10 to 14 days after surgery and pieces of special tape called Steri-Strips will be put over your incision. You may shower two days after the staples are removed. Pat your incision dry after your shower. The Steri-Strips may fall off after a few days. If they don’t, you can gently peel them off in five to seven days. It is normal for your incision to itch, feel numb or drain a little clear fluid. If you have staples, you may shower after three days, but do not soak or scrub the incision line. Also, do not clean the incision line with any substance because there is a possibility of dissolving the surgical glue.
- Showering after surgery requires physician approval. Make sure you ask your physician before you leave the hospital how much time should pass before you shower. Never soak or immerse your incision until the physician says you can. Look at your incision daily for signs of infection or irritation. If you can’t see your incision, look in a mirror or have someone else look at it. If you see any signs of infection, call your doctor’s office. Signs of infection are drainage (other than clear, reddish-yellow fluid), fever, increased pain or tenderness, redness and heat, and swelling. When your incision is completely healed, you may massage the area with a water-based lotion. This will be approximately four weeks after surgery.
Beginning your therapy
You may be up and moving on your surgery day, if your physician recommends it. Your nurse or physical therapist will help you. You will want to bend and straighten your knee two or three times a day while in the hospital. Mobility goals for the first day typically include sitting on the edge of the bed, walking with a walker for 10 feet and getting out of bed with assistance for your meals.
You will be given instructions on specific precautions to take after surgery. Your nurse or therapist will help you to the restroom and stay with you the entire time for your safety and to provide you with important education and tips on safe mobilization. Do not get up by yourself. If you have a nerve block, you will have a knee immobilizer on for all out-of-bed activity. Once the block is gone and the numbness has completely worn off, the immobilizer is not used. It can also help to wear rubber-soled shoes or nonslip socks whenever you get out of bed.
What can I expect the day after knee replacement surgery?
Mobility goals continue
You will be out of bed several times the day after surgery, but not alone. All activity must be done with assistance. You may be expected to walk 20 feet or more with your walker. You will be sitting in a chair for all your meals and should bend your knee at least 60 degrees, while working hard to get your knee as straight as possible when you extend it. Working with physical and occupational therapy and moving your knee throughout the day is very important. Your therapists will teach you about special safety precautions and specific exercises. Sit in your chair as much as possible. You will not use a pillow under your knee after your surgery. This is to allow for full extension and stretching to keep your knee from getting stiff. Your goal is at least 90 degrees of bend in your knee within a few days after surgery.
Many patients are concerned about pain after surgery and how well it will be controlled. Everyone experiences pain differently. Your pain will be controlled to a level that is tolerable for you. Orthopaedic staff members have experience helping patients manage their pain. Pain can be managed with anti-inflammatory medicine; ice; frequent, short bouts of activity; pain medicine; peripheral nerve blocks; and Tylenol. Narcotics will be ordered on an as-needed basis. This means you must ask the nurse for these medications. The doctor’s order for pain medication will have a time restriction. For example, a patient may only receive narcotic pain medications every four hours.
Possible side effects of medication
Pain medication and anesthesia can cause constipation, so your doctor may prescribe stool softeners or laxatives after surgery. If you normally have problems with constipation, let the doctors know what works best at home so we can try to do the same for you in the hospital. Drink plenty of water as well. Medication also may cause decreased appetite, dry mouth, itching, nausea and/or vomiting, and urinary retention. It may also cause severe drowsiness or confusion, although this is rare. Tell your nurse right away if you have any of these side effects, or if you feel you are not getting enough pain relief.
Plan your pain medications around therapy
It is important for you to plan on taking your pain medications around your physical therapy schedule. Most patients prefer to take the pain medication about 30 minutes before beginning their physical therapy. The combination of the pain control methods will help to manage your pain, though not completely eliminate it. You need to stay active — movement is critical. You may have ice or a cooling unit for your knee to take home with you. You can use regular ice when the cooling unit stops working. Remember — your postsurgical pain is temporary.
Equipment needed to go home
You will be using a wheeled walker when you go home. The physical therapist will help you decide how long to use the walker. A bedside commode will also likely be needed. Equipment that is recommended for your home may be covered by insurance. The case manager will secure these items for you before discharge. If you already own this equipment, please let your discharge planner know. Additional items, such as a tub bench and grab bars in the tub or shower, may be helpful during recovery. However, insurance companies will not pay for them or their installation. These items would be best purchased and installed before your surgery.
Staying in bed does not get you home more quickly, nor does it make you stronger. Prolonged bed rest can cause increased risk of bed sores, blood clots and pulmonary embolism. It also increases the risk of pneumonia, exercise intolerance, weakness and changes in blood pressure, decreased bone density and muscle mass, constipation and depression or a sense of helplessness.
What can I expect when I am discharged from the hospital?
Before you are discharged, you will receive written instructions from your nurse and possibly a case manager concerning medications, therapy, activity and precautions. These post-hospital care instructions are important to help ensure a successful recovery. Take this information home with you. Therapy or nursing will help you get to your vehicle and discuss any safety considerations regarding getting in and out of the car.
Follow-up care after discharge
Most patients go home after surgery. You can decide whether home therapy or outpatient therapy is the best choice for you. In rare instances, patients may need rehab placement in an outside facility if mobility level, care coach availability or home setting is not ideal for discharge directly home. It is important to know what your insurance company will pay for with regard to therapy coverage after surgery. Medical staff, case managers and physical therapists can recommend the appropriate level of care; however, your insurance provider will determine care based on coverage and contracts.
You will need a care coach at home
A care coach is the person who has agreed to stay with you for at least one week, day and night, after surgery. This person will help you with light house duties, provide standby assistance for mobility, especially when you walk to and from the bathroom, and help with pets and meals.
Symptoms after surgery
Your knee could be swollen for three to six months after surgery. You may notice a clicking noise when you walk. This is normal and is the result of the artificial surfaces coming together. You may have some numbness on the outside of your scar, which may last for a year or longer. You also may have soreness in your knee for three to six months after surgery. These symptoms are not serious and should go away.
Another important factor in your recovery is controlling any swelling you might have. The better the swelling is controlled, the easier it will be for you to move and strengthen your knee. Apply a cold pack or wrap to your knee for 20 minutes following all exercise and every four hours, if you are in a lot of pain. Wrap ice packs in a towel to protect your skin before you apply to your knee. Be sure to keep the incision dry. Place a pillow under your calf, not your knee, when elevating your leg. If you were given compression socks while in the hospital, you should wear them during the day for four weeks. They should be thigh-high in length. There are many alternatives in sporting goods stores if you prefer a different method for swelling control.
Restrictions and general rules following surgery
- Do not drive until you are cleared by your physician. Do not drive while on pain medication — it’s against the law. Depending on circumstances, it may take up to eight weeks before you are cleared to drive.
- High-impact activities, such as running, tennis and basketball, are not recommended, and you should not kneel on your new knee for at least six weeks.
- You will be instructed and educated about how much weight you can place on your leg. Follow your weight-bearing instructions from your surgeon and physical therapist.
- Let pain be your guide when moving your leg or hip.
- Use chairs with armrests to help you stand up and sit down.
- Always push up from the surface you are coming from. Do not lean and pull on your walker.
- Avoid using waterbeds.
- Avoid low, soft sofas and chairs. If necessary, add firmness to low or soft chairs by using pillows or folded blankets.
- Use your walker as instructed.
Recommendations once you are home
Your new knee is meant to be moved! Don’t let pain be the reason to not attend therapy today. Your therapist will assist you with reducing your pain. You are your best coach. Stay active. Be fit.
- Perform your home exercise program at least twice a day on your own or with family assistance
- Try to bend and straighten your knee as much as possible
- Do not wear your immobilizer at home unless instructed to do so or if you still have a nerve block; wear your knee brace when walking if you have a nerve block
- Walk as often as possible, with or without assistance as directed by your physician, nurse and therapist
- Monitor for signs of infection, such as fever, swelling, increased pain or redness
- Get out of bed for meals
- Wear slippers with good grips and backs on them whenever you get out of bed
- Keep a regular bedtime routine and do not sleep during the day
- Use an incentive spirometer as instructed by your physician/nurse/therapist
- Do any exercises assigned to you outside of your therapy sessions
Walking with a walker
Your physical therapist will teach you to walk properly with a walker. The assistive device will help you walk and take weight off your operative leg so your muscles can recover. It is important that you do not plant your leg and twist or turn your knee joint; this could damage your muscles and the stability of the joint. When getting up from a chair or toilet, do not use the walker for support. Push off of the armrest or seat with your hands.
Once you are standing, put both hands onto the walker handles. Keep your head up and look straight ahead. Stand up straight. When walking, use the wheels on the front of the walker to move forward and glide it like a grocery cart. It is important to remember that you cannot pull on a walker to get up. It will cause you to lose your balance. The walker is meant to relieve the load off your leg somewhat while you are healing.
Do not diet while you are healing from your surgery
Good nutrition — including eating a balanced diet high in protein and calories — is essential for proper wound healing. If you are diabetic, you will be put on a diabetic diet to keep your blood sugar under control. People with diabetes take longer to heal. The more your blood sugar is kept under control, the faster you will heal. Let your doctor know if you have food allergies or if you are vegetarian or vegan. Ask your nurse or doctor if you have any questions about your diet.
What can I do to prevent falls?
Begin a regular exercise program
Exercise is one of the most important ways to lower your chances of falling. It makes you stronger and helps you feel better. Exercises that improve balance and coordination, such as tai chi, are the most helpful. Lack of exercise leads to weakness, and increases your chances of falling.
Have your health care provider review your medications
As you get older, the way medicines work in your body can change. Some medications, or combinations of medications, can make you sleepy or dizzy and can cause you to fall.
Have your vision checked at least once a year
You may be wearing the wrong glasses and need your prescription updated, or have a condition, such as glaucoma or cataracts, that limits your vision. Poor vision can increase your chances of falling.
Make your home safer
About half of all falls happen at home, so here are some tips to make your home safer:
- If your home has stairs, discuss this with your physical therapist during your hospital stay for problem-solving tips and practice
- Remove things such as books and shoes from stairs and other places you walk
- Remove small throw rugs or use double-sided tape to keep them from slipping
- Remove or tape down extension cords
- Keep items you use often in cabinets you can reach easily without using a step stool
- Install grab bars next to your toilet and in the tub or shower
- Install nonslip mats on the floors of your bathtub and shower
- Improve the lighting in your home; hang lightweight curtains or shades to reduce glare
- Install handrails and lights on all staircases
- Wear shoes inside and outside the house; do not go barefoot or wear slippers