What is a total knee replacement?

A total knee replacement is a surgical procedure whereby the diseased knee joint is
replaced with artificial material. The knee is a hinge joint which provides motion at
the point where the thigh meets the lower leg. The thigh bone (or femur) abuts the
large bone of the lower leg (tibia) at the knee joint. During a total knee replacement,
the end of the femur bone is removed and replaced with a metal shell. The end of the
lower leg bone (tibia) is also removed and replaced with a channeled plastic piece
with a metal stem. Depending on the condition of the kneecap portion of the knee
joint, a plastic "button" may also be added under the kneecap surface.
The posterior cruciate ligament is a tissue that normally stabilizes each side of the
knee joint so that the lower leg cannot slide backward in relation to the thigh bone. In
total knee replacement surgery, this ligament is either retained, sacrificed, or
substituted by a polyethylene post. Each of these various designs of total knee
replacement has its benefits and risks.
What patients should consider a total knee replacement?
Total knee replacement surgery is considered for patients whose knee joints have been
damaged by either progressive arthritis, trauma, or other rare destructive diseases of
the joint. The most common reason for knee replacement in the United States is
severe osteoarthritis of the knees.
For further information, please see the Osteoarthritis article of MedicineNet.com.
Regardless of the cause of the damage to the joint, the resulting progressively
increasing pain and stiffness, and decreasing daily function lead the patient to
consider total knee replacement. Decisions regarding whether or when to undergo
knee replacement surgery are not easy. Patients should understand the risks as well as
the benefits before making these decisions.
What are the risks of undergoing a total knee replacement?

Risks of total knee replacement include blood clots in the legs that can travel to the
lungs (pulmonary embolism). Pulmonary embolism can cause shortness of breath,
chest pain, and even shock. Other risks include urinary tract infection, nausea and
vomiting (usually related to pain medication), chronic knee pain and stiffness,
bleeding into the knee joint, nerve damage, blood vessel injury, and infection of the
knee which can require re-operation. Furthermore, the risks of anesthesia include
potential heart, lung, kidney, and liver damage.]
What is involved with the preoperative evaluation for total knee replacement?
Before surgery, joints adjacent to the diseased knee are carefully evaluated. This is
important to ensure optimal outcome from the surgery. Replacing a knee joint which
is adjacent to a severely damaged joint may not yield significant improvement in
function. Furthermore, all medications which the patient is taking are reviewed. Blood
thinning medications such as warfarin (Coumadin), and anti-inflammatory
medications such as Aspirin, may have to be adjusted or discontinued prior to surgery.
Routine blood tests of liver and kidney function, and urine tests are evaluated for
signs of anemia, infection or abnormal metabolism. Chest x-ray and EKG are
performed to exclude significant heart and lung disease which may preclude surgery
or anesthesia. Finally, it is less likely to have good long-term outcome if the patient's
weight is greater than 200 pounds. Excess body weight simply puts the replaced knee
at an increased risk of loosening and/or dislocation.
A similar risk is encountered in younger patients who may tend to be more active,
thereby adding trauma to the replaced joint.
What happens in the postoperative period?
A total knee replacement generally requires between one and one- half to three hours
of operative time. After surgery, patients are taken to a recovery room, where vital
organs are frequently monitored. When stabilized, patients are returned to their
hospital room.
Passage of urine can be difficult in the immediate postoperative period, and this
condition can be aggravated by pain medications. A catheter inserted into the urethra
(a Foley catheter) allows free passage of urine until the patient becomes more mobile.
Physical therapy is an extremely important part of rehabilitation and requires full
participation by the patient for optimal outcome. Patients can begin physical therapy

forty-eight hours after surgery. Some degree of pain, discomfort, and stiffness can be
expected during the early days of physical therapy. Knee immobilizers are used in
order to stabilize the knee while undergoing physical therapy, walking, and sleeping.
They may be removed under the guidance of the therapist for various portions of
physical therapy.
A unique device that can help speed recovery is the continuous passive motion (CPM)
machine. The CPM machine is first attached to the operated leg. The machine then
constantly moves the knee through various degrees of range of motion for hours while
the patient relaxes.
Patients will start walking using a walker and crutches. Eventually, patients will learn
to walk up and down stairs and grades. A number of home exercises are given to
strengthen thigh and calf muscles.
How does the patient continue to improve as an outpatient after discharge from
the hospital?
It is important for patients to continue in an outpatient physical therapy program along
with home exercises for optimal outcome of total knee replacement surgery. Patients
will be asked to continue exercising the muscles around the replaced joint to prevent
scarring (contracture) and maintain to muscle strength for the purposes of joint
stability.
The wound will be monitored by the attending physicians and their staff for healing.
Patients also should watch for warning signs of infection including abnormal redness,
increasing warmth, swelling, or unusual pain. It is important to report any injury to
the joint to the doctor immediately.
Future activities are generally limited to those that do not risk injuring the replaced
joint. Sports that involve running or contact are avoided, in favor of leisure sports,
such as golf, and swimming. Swimming is the ideal form of exercise, since the sport
improves muscle strength and endurance without exerting any pressure or stress on
the replaced joint.
Patients with joint replacements should alert their doctors and dentists that they have
an artificial joint. These joints are at risk for infection by bacteria introduced by any
invasive procedures such as surgery, dental or gum work, urological and endoscopic
procedures, as well as from infections elsewhere in the body.

Patients are recommended to take antibiotics before, during, and immediately after
any elective procedures in order to prevent infection of the replaced joint.
Though infrequent, patients with total knee replacements can require a second
operation years later. The second operation can be necessary because of loosening,
fracture or other complications of the replaced joint. Re-operations are generally not
as successful as the original operation and carry higher risks of complications. Future
replacement devices and techniques will improve patient outcomes and lead to fewer
complications.

Total Knee Replacement At A Glance

Patients with severe destruction of the knee joint associated with progressive
pain and impaired function may be candidates for total knee replacement.
Risks of total knee replacement surgery have been identified.
Physical therapy is an essential part of rehabilitation after total knee
replacement.
Patients with artificial joints are recommended to take antibiotics before,
during, and after any elective invasive procedures (including dental work).