Total Knee Replacement Surgery

• What is a total knee replacement?
• When am I a candidate for total knee replacement?
• What does it entail to have a total knee replacement surgery?
• What is my activity level when I get home?
• Is it dangerous to undergo total knee replacement surgery?
• What type of implant will be used?
• How can I avoid Stiffness.
• Should I wait as long as possible to have my knee replacement surgery?
• One last word.
• Back in the game patient’s stories:
• Why should I have my surgery at the Hospital for Special Surgery?

What is a total knee replacement?

Total knee replacement is the replacement of the entire knee with a metal surface replacement and a plastic insert. During a total knee replacement, all three compartments - the medial, lateral and patellofemoral compartment - are replaced. Components are usually fixed with cement. Most modern knee replacements are relatively bone preserving and just remove the superficial layer of cartilage and bone and replace it with a metal-on-plastic implant. Today we differentiate between posterior cruciate ligament preserving, so-called cruciate retaining and posterior cruciate ligament sacrificing, so-called posterior stabilized knee replacement. Dr. Boettner performs both types of knee replacement and will discuss with you at the time of the appointment which one might be more appropriate for you.

When am I a candidate for total knee replacement?

Prior to indicating total knee replacements, all patients should have non-operative treatment first. Total knee replacement is not a benign procedure and does have medical and surgical risks and therefore non-operative treatment should be considered first before moving on with replacement surgery. Non-operative treatment in general consists of:

• anti-inflammatories to relieve pain and swelling (Ibuprofen (Motrin), Votaren, Naproxen (Aleeve),
• cortisone injections into the knee,
• lubricant injections,
• Plasma Rich Protein (PRP) injections
• unloader braces,
• physical therapy to strengthen the muscles and improve flexibility
• weight loss
• activity modification: avoiding activities that cause significant pain

Especially cortisone injections are often very helpful since they they usually result in complete relief for up to six months. Braces are used to unload the arthritic side of the knee, so called unloader braces. Lubricant injections receive a lot of media attention; however, patients do not respond to them as predictably as they do to cortisone injections and especially for patients with advanced arthritis they are usually not beneficial. Activity modification and weight loss are very simple ways to decrease load on the knee. If you imagine that the knee will see up to eight times your body weight during certain exercises, it becomes clear how helpful it can be to drop even a few pounds to decrease the load on the arthritic knee. There is also little question that obesity is the driving force behind knee arthritis. So if you want to prophylactically decrease your chance of developing arthritis, keeping your weight within the recommended range can be extremely helpful. Activity modification is another option to decrease your pain related to arthritis, especially when we talk about recreational activities. The quote “if you have pain with running then do not run” does hold true for patients with arthritis. This is primarily true for activities one cannot do after a total knee replacement, like running, playing basketball or rock climbing. There are certain activities that are just essential to live a fulfilled life and once the arthritis affects those activities and using other non-operative modalities does not provide pain relief, then we will often discuss the option of knee replacement surgery. Without pain no knee replacement. Insurance companies also usually require bone on bone arthritis on radiographs to cover the procedure

What does it entail to have a total knee replacement surgery?

After you undergo medical clearance you are admitted to the hospital the day of your surgery. You will then undergo a spinal epidural anesthesia, a regional anesthesia that allows us to control your pain during surgery and after surgery and has less risks than general anesthesia. Dr. Boettner also uses regional nerve blocks and periarticular injections to reduce your pain after surgery. The surgery itself takes approximately one hour. In the past a tourniquet was often used to reduce the blood flow to the leg, nowadays, Dr. Boettner avoids a tourniquets as much as possible to decrease postoperative pain and facilitate early recovery. After the surgery you initially will be transferred to a postoperative recovery room where your vital signs and the weaning off of the anesthesia is monitored by an anesthesiologist. You are then transferred to the floor where the day after surgery physical therapy and rehabilitation will start. We prefer to keep you in the hospital at least one night to make sure you are safe and comfortable when you return home. Most patients stay one or two nights. By the time you leave the hospital, you should be able to walk 100 feet with either a cane or walker and you should be able to walk a flight of stairs. Dr. Boettner recommends that you are discharged home. Inpatient rehabilitation is for most patients neither covered by insurance nor beneficial. We will provide you with a CPM machine and a physical therapist that will check on you during the week to make sure that you make adequate progress. After you get home I recommend to take it easy, ice the knee and focus on range of motion and make sure that the swelling comes down. Limit your waling in the 2-4 weeks until the range of motion has improved. You should work on full extension and flexion with the goal to achieve 90 degrees of knee flexion by 3 days after surgery, 100 deg. by 5 days and 110 deg. by 10 days after surgery. Also work on full extension placing a towel under the ankle and pushing your knee straight by activating the quadriceps pushing the knee into the bed. Make sure the incision is dry and contact the office if there is drainage.

Do Not massage the knee or the incision!

Do Not use weights or rubber bands to strengthen your knee!

Do Not do not walk too much in the first 3-4 weeks!

What is my activity level when I get home?

By the time you go home you should be able to move around in your apartment and house and take care of yourself. We do close incisions with resorbable/dissolvable stitches covered by surgical glue and therefore you should be able to shower right after you get home. Remove any dressing by 5 days after surgery. During the day, you will be required to work for three to six hours on a CPM bending machine to increase the range of motion of your knee. Dr. Boettner also recommends that you do not walk outside the house the first three weeks until the swelling in the knee is down and you have achieved at least 120 degrees of flexion and full extension. During your early postoperative time, you will take narcotic pain medication to control pain. Total Knee replacements can cause quite a bit of pain and it is perfectly fine to take narcotics during the first 3-4 weeks, you need to be comfortable enough to do your range of motion exercises. Recovery is all about range of motion!

Is it dangerous to undergo total knee replacement surgery?

A total knee replacement is a major surgery, however, by haveing medical clearance in advance to your major complications are usually avoided. You will spend one day a few weeks before surgery to undergo some basic testing. If you have preexisting heart disease you will have to have clearance from your cardiologist. Today most patients will undergo the surgery without any complications and will achieve a well-functioning knee. Risks of the surgery include surgical risks like intraoperative fracture or damage to ligaments as well as risks to damaged neurovascular structures around the knee. Nerve injuries of larger nerves, like the peroneal nerve are possible and can result in significant pain, functional limitation (foot drop) and long term chronic sympathetic pain syndromes. The frequency is about 1 in 1500 surgeries. There is a small risk of deep implant infection. Infection rates at Hospital for Special surgery are approximately 0.5%. Dr. Boettner’s personal rate of deep implant infections is less than 0.2%. Dr. Boettner recommends antibiotic prophylaxis whenever you see a dentist or have other invasive procedures after you have a knee replacement surgery to minimize the risk of infection. There is also a risk that your knee could be stiff or unstable after surgery. While instability after surgery is usually related to how the surgery is done, stiffness is affected by both the surgical technique as well as your willingness and motivation to work on your range of motion after surgery. An experienced surgeon can today avoid most complications, however, some risks remain. Dr. Boettner has performed more than 4000 total and partial knee replacements. He applies minimal invasive soft tissue preserving surgical techniques to minimize pain and optimize your function. You will be in good hands. Depending on the type of knee replacement there can be clicking and almost all patients have some degree of numbness on the outside of the incision.

Besides the surgical risks of knee replacement surgery there are also medical risks including blood clots as well as serious complication like pulmonary emboli. We use postoperative pneumatic compression devices to increase the blood flow in the lower extremities and will usually recommend either Aspirin or Xarelto based on your individual risk to prevent postoperative blood clots. Serious complications (heart attack, stroke) are very rare if you do not considerable prior heart or lung problems

What type of implant will be used?

Dr. Boettner uses different types of implants. Primarily we work with the Legion primary knee replacement from Smith & Nephew as well as with the Ortho Development Balanced Knee system that was designed by Dr. Boettner. Please ask Dr. Boettner if you have specific questions of what type of knee replacement will be used in your individual case. We use cruciate retaining knee designs for patients that engage in higher activity levels or for heavier male patients. Most other patients receive posterior stabilized knee replacement since the optimize range of motion.

Should I have my patella resurfaced ? In Dr. Boettner’s experience loosening of the tibial or femoral component is rather rare. In 12 years in practice only 2 femoral components and 3 tibial components have loosened. However, patella button loosening is more common especially in patients that are heavy or have to work (out) intensely. The following table gives you an idea when preservation of your natural patella might be beneficial. Please discuss the options with Dr. Boettner:

How can I avoid stiffness?

Most of our patients will have excellent range of motion at 4-8 weeks after surgery. Our data suggest that the average range of motion after total knee replacement in our practice is more than 125 degrees. However, during the first few weeks the knee will always feel tight and stiff. That is normal. Patients can get into trouble if they are to active to early. We recommend to not walk outside the house until the swelling is down and you can fully extend the knee and bend at least 120 degrees. Do not walk too much and do not work on strength until your range of motion is 120 degrees.

Should I wait as long as possible to have my knee replacement surgery?

Do not wait as long as possible! Dr. Boettner recommends regular follow-up visits every 3 to 6 months if you are a patient with bone-on-bone arthritis in order to monitor the degree of deformity, the amount of bone loss from the arthritis and the degree of stiffness. In general, you can live with an arthritic knee until you feel that you no longer can handle the pain and functional disability; however, if your knee starts to get stiff, if the deformity increases (more bowing or knocked knee appearance) or if you develop progressive bone loss, Dr. Boettner might recommend to proceed with knee replacement surgery right away. Especially patients with preoperative stiffness should consider undergoing surgery sooner rather than later because preoperative stiffness is a very important predictor for postoperative range of motion and waiting until the last minute with a very stiff knee can have significant impact on your functional outcome after surgery. Please discuss this with Dr. Boettner to make sure that continuing non-operative treatment is the appropriate way to handle your arthritic knee.

One last word.

Total knee replacements have not the best reputation and some patients are concerned about the pain that can be associated with surgery. Patients are also worried not to achieve the desired activity level after the surgery. Dr. Boettner specializes in knee replacement surgery; our surgical technique and perioperative pain management are aimed at keeping you comfortable throughout the recovery. We utilize minimal invasive surgical techniques, apply medications to minimize blood loss, use pain medications already before the surgery to make sure you do not experience severe pain and use an intraoperative cocktail injected into the knee tissues to minimize postoperative pain and swelling. Not doing the surgery when it is indicated is not a smart alternative. Let’s discuss your concerns and I am sure you will feel that you can trust us with your care.

Back in the game patient’s stories:

Please find our back in the game stories on the HSS website. backinthegame.hss.edu/

Why should I have my surgery at the Hospital for Special Surgery?

Please find more information about the Hospital for Special Surgery here www.hss.edu/reasons-to-choose-hss.asp

If you are suffering from debilitating hip pain or hip arthritis or have been told you need a total hip replacement we are happy to see you in one of our office locations in Manhattan, Uniondale Long Island or White Plains Westchester. Dr. Boettner is a hip replacement specialist with more than 10 years of experience. Being able to perform both anterior and posterior approach hip replacement as well as resurfacing he will offer you a tailored approach for your individual situation. To contact the office please , send an email to [javascript protected email address] or schedule an appointment by using the form on this website.

Learn more about total hip replacement at hss.edu link: www.hss.edu/condition-list_knee-replacement.asp