Knee Replacement Surgery

(Total Knee Arthroplasty, Knee Arthroplasty, Total Knee Replacement, Knee Replacement)

Procedure Overview

What is a knee replacement surgery?

Knee replacement, also called arthroplasty, is a surgical procedure to replace a damaged knee with a prosthesis (an artificial joint). This surgery may be considered for someone who has severe arthritis or a severe knee injury.

Various types of arthritis may affect the knee joint. Osteoarthritis, a degenerative joint disease that affects mostly middle-aged and older adults, may cause the breakdown of joint cartilage and adjacent bone in the knees. Rheumatoid arthritis, which causes inflammation of the synovial membrane and results in excessive synovial fluid, can lead to pain and stiffness. Traumatic arthritis, arthritis due to injury, may cause damage to the cartilage of the knee.

The goal of knee replacement surgery is to replace the parts of the knee joint that have been damaged and to relieve knee pain that cannot be controlled by other treatments.

Other related procedures that may be used to help diagnose joint disorders include x-ray, joint aspiration, bone scan, magnetic resonance imaging (MRI), computed tomography (CT scan), arthroscopy, and arthrography. Please see these procedures for additional information.

Anatomy of the knee:

Joints are the areas where two or more bones meet. Most joints are mobile, allowing the bones to move. Basically, the knee is two long leg bones held together by muscles, ligaments, and tendons. Each bone end is covered with a layer of cartilage that absorbs shock and protects the knee.

There are two groups of muscles involved in the knee, including the quadriceps muscles (located on the front of the thighs), which straighten the legs, and the hamstring muscles (located on the back of the thighs), which bend the leg at the knee.

Tendons are tough cords of connective tissue that connect muscles to bones. Ligaments are elastic bands of tissue that connect bone to bone. Some ligaments of the knee provide stability and protection of the joints, while other ligaments limit forward and backward movement of the tibia (shin bone).

The knee consists of the following:

• tibia - shin bone or larger bone of the lower leg.
• femur - thighbone or upper leg bone.
• patella - kneecap.
• cartilage - a type of connective tissue made up of cells and fibers that covers the surface of a bone at a joint. Cartilage is wear-resistant and helps reduce the friction of movement within a joint.
• synovial membrane - a tissue that lines the joint and seals it into a joint capsule. The synovial membrane secretes synovial fluid (a clear, sticky fluid) around the joint to lubricate it.
• ligament - a type of tough, elastic connective tissue that surrounds the joint to give support and limits the joint's movement.
• tendon - a type of tough connective tissue that connects muscles to bones and helps to control movement of the joint.
• meniscus - a curved part of cartilage in the knees and other joints.

Reasons for the Procedure

Knee replacement surgery is a treatment for pain and disability in the knee. The most common condition that results in the need for knee replacement surgery is osteoarthritis.

Osteoarthritis is characterized by the breakdown of joint cartilage and adjacent bone in the knees. Damage to the cartilage and bones limits movement and may cause pain. Persons with severe degenerative joint disease may be unable to do normal activities that involve bending at the knee, such as walking or climbing stairs, because they are painful. The knee may swell or “give-way” because the joint is not stable.

Other forms of arthritis, such as rheumatoid arthritis and arthritis that results from a knee injury, may also lead to degeneration of the knee joint. In addition, fractures, torn cartilage, and/or torn ligaments may lead to irreversible damage to the knee joint.

If medical treatments are not satisfactory, knee replacement surgery may be an effective treatment. Some medical treatments for degenerative joint disease may include, but are not limited to, the following:

• anti-inflammatory medications
• pain medications
• limiting painful activities
• assistive devices for walking (such as a cane)
• physical therapy
• cortisone injections into the knee joint
• weight loss (for obese persons)

There may be other reasons for your physician to recommend a knee replacement surgery.

Risks of the Procedure

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• bleeding
• infection
• blood clots in the legs or lungs

The replacement knee joint may become loose, be dislodged, or may not work the way it was intended. The joint may have to be replaced again in the future.

Nerves or blood vessels in the area of surgery may be injured, resulting in weakness or numbness. The joint pain may not be relieved by surgery.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• In addition to a complete medical history, your physician may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your physician.
• You will be asked to fast for eight hours before the procedure, generally after midnight.
• You may receive a sedative prior to the procedure to help you relax.
• You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
• Arrange for someone to help around the house for a week or two after you are discharged from the hospital.
• The area around the surgical site may be shaved.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Knee replacement requires a stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Knee replacement surgery may be performed while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your physician will discuss this with you in advance.

Generally, knee replacement surgery follows this process:

1. You will be asked to remove clothing and will be given a gown to wear.
2. An intravenous (IV) line may be started in your arm or hand.
3. You will be positioned on the operating table.
4. A urinary catheter may be inserted.
5. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
6. The skin over the surgical site will be cleansed with an antiseptic solution.
7. The physician will make an incision in the knee area.
8. The physician will remove the damaged parts of the knee joint and replace them with the prosthesis. The knee prosthesis is made up of metal and plastic. The two most common types of artificial knee prostheses used are cemented prostheses and uncemented prostheses. A cemented prosthesis attaches to the bone with surgical cement. An uncemented prosthesis attaches to the bone with a fine mesh into which the bone grows to attach to the prosthesis. Sometimes, a combination of the two types is used to replace a knee.
   
   The prosthesis is generally comprised of three components: the tibial component (to replace the top of the tibia, or shin bone); the femoral component (to replace the two femoral [thighbone] condyles and the patella groove); and the patellar component (to replace the bottom surface of the kneecap that rubs against the thighbone).
9. The incision will be closed with stitches or surgical staples.
10. A drain may be placed in the incision site to remove fluid.
11. A sterile bandage/dressing will be applied.

After the Procedure

In the hospital:

After the surgery you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. Knee replacement surgery usually requires an in-hospital stay of several days.

It is important to begin moving the new joint after surgery. A physical therapist will meet with you soon after your surgery and plan an exercise program for you. A continuous passive motion (CPM) machine may be used to begin the physical therapy. This machine moves your new knee joint through its range of motion while you are resting in bed. Your pain will be controlled with medication so that you can participate in the exercise. You will be given an exercise plan to follow both in the hospital and after discharge.

You will be discharged home or to a rehabilitation center. In either case, your physician will arrange for continuation of physical therapy until you regain muscle strength and good range of motion.

At home:

Once you are home, it is important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit.

To help reduce swelling, you may be asked to elevate your leg, apply ice, or wear support hose or special compression boots.

Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Notify your physician to report any of the following:

• fever
• redness, swelling, bleeding, or other drainage from the incision site
• increased pain around the incision site

You may resume your normal diet unless your physician advises you differently.

You should not drive until your physician tells you to. Other activity restrictions may apply. Full recovery from the surgery may take several months.

It is important that you avoid falls after your knee replacement surgery, because a fall can result in damage to the new joint. Your therapist may recommend an assistive device (cane or walker) to help you walk until your strength and balance improve.

Making certain modifications to your home may help you during your recovery. These modifications include, but are not limited to, the following:

• proper handrails along all stairs
• safety handrails in the shower or bath
• shower bench or chair
• raised toilet seat
• long-handled sponge and shower hose
• dressing stick
• sock aid
• long-handled shoe horn
• reaching stick to grab objects
• removing loose carpets and electrical cords that may cause you to trip
• avoiding stair-climbing until recommended by your physician

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.