Knee Surgery Education

Understanding all aspects of your surgery and that everyone recovers at a different rate may help lead to a faster and smoother recovery.

You are not alone in your decision to have knee arthroplasty (replacement) surgery. Chances are that the reason you are having joint surgery is to relieve your severe pain and / or so you may resume normal activities.
 

The Knee Joint

A joint is formed where two or more bones meet. The knee joint is a hinge-type joint and is formed where the thighbone (femur) meets the shinbone (tibia). The thighbone is rounded on the end and rocks back and forth on the flat surface formed on the end of the shinbone. A smooth cushion of articular cartilage covers the surface ends of both these weight bearing bones. This cartilage is kept slippery by fluid (synovial fluid) made in the joint lining (synovial membrane). Since the cartilage is smooth and slippery, the bones move against each other easily and without pain. Large ligaments, tendons and muscles around the knee joint hold the bones in place. Located on the front of the knee is the kneecap (patella). It keeps the tendon that comes across the front of the knee from rubbing against the joint.

Causes or Reasons for Knee Arthroplasty (Replacement)

  • Arthritis: Arthritis is a wearing away of the surfaces (articular cartilage) of the joint, which can be caused by aging, or disease. As the cartilage wears away, the raw bones rub together whenever the joint moves. This rubbing causes pain and further roughening of the surfaces of the bone.
  • Osteonecrosis:  If the blood supply for the thighbone is decreased, part of the bone will die and break under weight bearing. The result is a very painful joint.
  • Injuries: Sports or work related injuries to the ligaments or other cartilage in the knee could cause abnormal wearing of the cartilage.

Surgery with a Team Approach

With your decision to have knee surgery, you have taken the first step toward freedom from hip pain and return to the activities you wish to do. Joint arthroplasty (replacement) is an elective procedure and you have a lot of choices of where to have it done. The philosophy of the Cedars-Sinai Joint Replacement Program is geared to making your surgical experience as easy and pleasant as possible. A multidisciplinary healthcare team, whose goal is to give you the best care and to help you regain the ability to care for yourself as soon as possible, will manage your care at Cedars-Sinai. The program is an aggressive one that allows you to be functional in a short time. The mindset is that "I am not really sick, I am here to have my joint replaced." Don't forget, we have a staff of trained professionals all working together for your success. We will be with you all the way. We want to educate and assist you and your family or significant other on your way to recovery.

Preparing for Your Surgery

Knee arthroplasty (replacement) surgery starts with a multidisciplinary education program, to help prepare you for the surgery and the rehabilitation program required after surgery. You will learn what you should and should not do, what to expect, what is expected of you, and whom you can contact if you have any questions or problems at any time during your course of treatment. Family or significant other participation is encouraged, in order to educate everyone involved with your care.

A nurse will be working with the surgeon, operating room services, anesthesiology, and case management (for needs after hospitalization), to make the patient flow a seamless process.

You are encouraged to get out of hospital gowns and into comfortable sports cloths as soon as possible. Families or your caregivers are asked to participate in your therapy so they can keep you on track after discharge. Because of this preoperative preparation, you will already have some knowledge about your hospital stay and what you will need at home even before you are admitted. So hopefully there should be less anxiety as you progress through your pathway and are discharged. The anticipated hospital stay following knee surgery is usually three to four days, including the day of surgery. As you meet discharge criteria, you will be discharged with appropriate information regarding home care services, or if needed, transferred to a sub acute unit (rehabilitation) in the community.

Before Your Surgery

Since knee surgery is usually scheduled in advance, there is a lot you can do before surgery to make your recovery in the hospital and at home go smoothly. In your surgeon's office you can fill out forms to schedule your surgery, hospital admittance, pre-testing and presurgery education program. You will receive calls from Cedars-Sinai Medical Center to confirm your surgery date, financial information and your attendance at our Multidisciplinary Preoperative Training and Education Program. If your doctor has not completed pre-operative tests you will be scheduled for testing at the Surgery Assessment and Testing Program.

Carefully follow your healthcare team's advice about:

  • Changes you should make in your diet
  • Any exercises you should start, stop, or keep doing (exercises from the Multidisciplinary Training and Preoperative Training Program).
  • If needed, helping your recovery by losing or gaining a few pounds
  • Stopping or continuing the medicines that you regularly or occasionally take, including prescription medicines, over-the-counter medicines, natural remedies (herbal medicines) and dietary supplements
  • If you take daily insulin, heart or blood pressure medicine, ask your doctor at what time you should take your medicine the day before and/or the morning of surgery

If you are a smoker, nicotine can slow down the healing process, so you may want to quit smoking before surgery. Talk with your doctor before using nicotine replacement products such as a patch, gum or cigarette substitute.

Insurance Coverage

To avoid surprises later, learn about your insurance coverage. Talk with your benefits manager at work or call your insurance company and find out what will be paid for by the insurance and what must be paid for by you. The following are some examples:

  • Equipment such as commode or raised toilet seat, walker, crutches or cane.
  • Medication on discharge: Pain medication such as Vicodan and a blood thinner such as Fragmin.

Planning for Returning Home

Even before you have surgery, think about going home. You will be discharged from the hospital by your surgeon when your medical condition is stable. If you are going home alone then you need to be able to walk safely, including stairs if needed. If you cannot do this by the time of discharge, then the social worker will have been working with you for placement in a community rehabilitation facility. The average length of stay in the hospital is three to four days. Since this surgery is pre-planned, please think about your home care needs and if discharge home is the right option? Once home, it's normal to have "good" and "bad" days. But if you continue exercising, there will be more good days and your general condition is likely to improve.

Planning Your Discharge

You will be evaluated everyday after surgery by a multidisciplinary team, including nurses, therapists, social worker, case manager, your doctors and yourself. The goal is to get you home safely. If you are medically stable, but not yet mobile enough to be discharged home safely, then a social worker will help make arrangements to a lower level of care facility in the community. If you need to be transferred to another facility for rehab, the social worker will help you in making that move, including determining insurance coverage.

The physical and occupational therapist will determine any special equipment and therapies that you might need and work with you and the social worker or case manager to order the appropriate items and service.

*If you live alone or have limited support system, and you know that you will need short term care or assistance please inform the health care team at the Multidisciplinary Training and Pre-operative Education program or you can call the Social Service department to start working on arrangements before you come into the hospital.
 

Preparing Your Home: Helpful Hints

Becoming aware and removing hazards in your home can help make your recovery easier and safer. If necessary, get help rearranging the rooms in your home to make it easier to walk around safely. Think about maneuvering a walker or crutches. Remove throw rugs and objects on the floor. Keep items you use often within easy reach. Move items, so you are not reaching up high or bending down low. Move electrical cords out of the way. Make sure your house is well stocked with groceries and food.

Check out your usual sitting areas. If you have any hip precautions, following them will affect where and how you sit, and how you should get up from a sitting position. A good rule to remember when sitting is always sit with your hips higher than your knees. Sit in your favorite chair; are your hips higher then your knees? If not, you can raise the level of your hips by placing a firm pillow in the seat.

Once Home: Helpful Hints

Avoid uneven floors or wet floors in the bathroom and kitchen. Watch for pets that may jump on you or run in your path. Wear rubber soled and low, closed heeled shoes to prevent slipping. Use your walker and crutches and hold onto handrails when using cane. Keep rooms well lit even at night.

Transportation Home

Patients go home as a passenger in a car. You are taught how to get in and out of a car before you leave. There is a wheelchair van service for a nominal fee, which can be arranged for you. Ambulance service is used only in specific cases, as set up for you by the social worker.

Family and Friends: An Important Role in Your Recovery

Your family and friends are especially important while you recover and adjust. They can assist you at this time and help make your home safer so you can go about your activities without hurting yourself. They can also help you with grocery shopping and help with preparing food. They can also cheer you on and celebrate when you walk a little farther, or accomplish a new task. Most insurance policies will not pay for 24-hour care, however, if you feel you need help with daily activities (bathing, shopping) the social worker has a list of agencies which can be given to you, so that arrangements can be made to hire someone to help you.

Arrangements for Surgery

  • When you come in for surgery or even when you are going for pre-admission, it's a good idea to have someone with you. They can listen and take notes for you.
  • Make a list of all medicines you are taking and any allergies to medicine or food that you have. Bring this list with you and give it to the admitting nurse.
  • You will be told about your rights for advanced directives, which are your written directions for your care, should you become unable to make decisions. If you have a living will and or health care power-of-attorney or advanced directive, bring a copy of these with you. If you have questions about advanced directives, call the Social Service department.
  • Report any health changes since your pre-surgery physical exam to your surgeon. Tell your surgeon if you get any cuts scrapes or sores on the affected leg. Tell your surgeon if you have any signs of infection, such as chills, fever, and coughing or runny nose within a week of your scheduled surgery.
  • You must stop eating and drinking by midnight the night before surgery. This keeps the stomach empty, which will reduce nausea and vomiting. In the morning, the day of your surgery, you can shower or bath, brush your teeth and shave. Do not eat or drink anything.
  • However, follow your instructions from your primary physician about taking any of your daily medicine or any pre-surgery medicine ordered by your surgeons or physicians.
  • Be sure to arrive at the hospital the day of your surgery, at the time told to you my your surgeon's office.

Be sure to bring:

  • Your insurance card and a picture ID
  • A blank check or your credit card number and its expiration date (for any equipment and discharge medication not covered)
  • Your glasses, dentures or hearing aide, if you use them
  • Shoes with nonskid soles and a closed heel (not too tight, as your foot may be a bit swollen after surgery)
  • A knee-length robe
  • Clothing that will be easy to put on and comfortable to wear home
  • Any items you were asked to bring during the Multidisciplinary Training and Pre-operative Education Program
  • Cedars-Sinai Medical Center does not have shampoo, shaving cream, deodorant or hand-held mirrors


Your Surgery: Day 1

Before Surgery

At the hospital, check in at the front desk of the Cedars-Sinai South Tower entrance. Someone will bring you to the 7th floor lobby to wait until the nurse from surgery comes to take you to the pre-surgery holding room. In the holding room, a nurse will help you get ready for surgery and go over any last minute questions. An anesthesiologist will talk to you and explain the type of anesthesia that will be used during surgery. An intravenous tube (IV) is placed in your arm or back of your hand. This tube supplies your body with necessary medicines and fluids. You may be given medicine to make you drowsy and relax you just before you go into the operating room.

When you go to the surgery holding room, your family or significant other and friends can wait for you in the 7th floor lobby waiting area. Surgery usually lasts one to three hours. You will be in the recovery room for another two to three hours. Someone will update your family or significant other or friends, as your surgery and recovery progress.

Surgery

There are wires and tubes attached to or placed in your body. These help monitor your body's functions, remove excess fluid, and help you breath during surgery. Your hip area is scrubbed with a germ killing soap. When everything is ready, your surgeon makes an incision in your hip. Your surgeon will explain the exact surgical procedure to you. Then your incision is stitched or stapled and then dressed with bandages. You will then be placed in your bed and taken to the recovery room.

Recovery Room

You will gradually wake up during this time. You may feel groggy from the anesthesia and will still have tubes and monitors attached. When you wake up you will notice:

  • Special sequential compression selves (stockings) will be on both legs to help blood circulation and prevent blood clots
  • A triangle-shaped pillow (abduction pillow) or regular pillow between your legs to keep your legs and hip in the best position for healing
  • The intravenous tube (IV) for continued fluids, antibiotics and possible blood transfusions
  • A drain (hemovac) that will remove the excess blood till it clots
  • A drain (foley catheter) in your bladder that will remove urine, so that you do not need to move to get on a bedpan right after surgery

The nurses will keep a close watch on your recovery and help to make you comfortable. If you need pain medicine, don't wait too long to ask for it. It is easier to prevent pain than to stop pain or catch up with it once it starts. The nurses will be asking you to "pedal" your feet up and down and if you have feeling in your legs and feet - especially in the leg with the new hip replacement. It is important to tell your nurse if you feel numbness, tingling or pain in your feet and legs.

When you are fully responsive and your blood pressure, pulse and respiration are stable, the recovery room nurses will transport you to the Orthopedic Unit for the next phase of your recovery.

Recovery Expectations

Everyone's recovery rate is different and how quickly you recover depends in part on your physical health and level of activity before surgery and how complex your surgery was. Your participation in the recovery program is very important. The hospital staff will monitor your medical condition and do the things you cannot do for yourself. As you become more active, you need to become more involved in your recovery. The Cedars-Sinai Joint Replacement Program has developed a guide or pathway (flow or map) of the usual recovery program from the first day, right through to your discharge from the Orthopaedic Unit. It is important to us to make your hospital stay and experience informative for a faster and easier recovery.

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