[ photo by Askar Abayev ]

What to expect after total knee replacement.

Your mom finally made the decision to have a knee replacement. She could not hold off any longer. She was in so much pain, just moving around the house was a chore. She had been under the care of a primary care sports medicine physician for the past few years because of the knee pain. She was diagnosed with knee osteoarthritis...both knees actually, but the right knee always felt a lot worse than the left.

Through the use of knee joint steroid injections and a couple of rounds of physical therapy her sports medicine doctor was able to help her control her symptoms for nearly three years. Unfortunately, the last couple of injections really did not provide any sustained relief and doing the prescribed exercises she had learned in therapy was just so painful she had trouble getting through them. Her doctor referred her to one of his surgeon partners who specializes in joint replacements. This surgeon confirmed that a total knee replacement would be the next option in allowing your mom to maintain her activity level while having less pain. 

Post knee replacement surgery considerations.

The surgery is scheduled for a couple weeks out, but now you are wondering what to expect after the knee surgery. Your mom is widowed and lives alone in her house. There are a few steps to get in and despite you trying to convince your mom to move her bedroom to one of the first floor rooms, she is insistent on keeping her room upstairs. You work full time and are concerned with how she will be able to manage when she gets home. Her surgeon is hopeful she will do well enough with the surgery that she will be able to go home with home health care in place a day or two after the surgery, but there is the possibility she will need some inpatient rehabilitation before she will safely get back home. 

Expected course following knee replacement.

Let’s discuss what to expect those first few days after the knee surgery and just what is involved in the decision making process. First off, let us assume the surgery goes as expected without any complications. Sometimes there is large amount of blood that is lost and the patient might require a blood transfusion, but this does not happen often.

The anesthesiologist, just prior to the surgery, administers a nerve block. This allows for great pain control immediately post-operatively and can last for up to 36 hours. The benefit of this is that it requires less use of systemic pain control medications (i.e. IV narcotics)  in that initial day after surgery. These oral and IV medications can cause changes to a person’s mental status and nausea, so the less that needs to be used the better. This is especially true in elderly or those with declining kidney function due to decreased ability to clear those medications from the system. 

Your mom had the nerve block performed and her first day, she felt great. Within that first day, both physical therapy (PT) and occupational therapy (OT) came to work with her. She still had some numbness in her right knee. She was helped up from the side of the bed to stand and then walk with a walker and PT’s assistance!

The PT also worked on getting her to start bending her knee, which wasn’t the most comfortable at first. There is quite a bit of stiffness after this surgery, but a good outcome from the knee replacement surgery hinges on gaining “functional” range of motion, which is at least 90 degrees of flexion, or bending, of the knee. This is the amount of bend necessary for someone to be able to do basic tasks such as getting up from a chair or the toilet.

It is also important for the knee to be able to move into full extension as a fully extended knee is necessary for a normal gait pattern. These goals of range of motion certainly will not be achieved in the first day or generally the first few days after surgery, but getting started right away on that goal is of utmost importance.

Your mom’s pain control is very good, so she is able to get some bend in that knee, and is almost able to get it into full extension. The OT comes to work with her. They see how she does getting on and off the toilet. She does okay but still needs moderate assist to stand up off the commode and get her pants pulled back up.

Typical pain control after knee replacement.

It is now about a day and half since your mom’s knee replacement surgery. Her nerve block has pretty much worn off. The nursing staff is excellent at keeping your mom’s knee wrapped with ice. The use off ice is also a very good method of controlling pain that also does not have the systemic effect that oral medications can have. She is receiving Tylenol scheduled every six hours and has taken a few doses of Tramadol, usually just after she has moved around with therapy or the nursing staff. 

The case manager has informed you that she will be medically stable to discharge tomorrow. She could go home with home health care in place, but the therapists have said she will need someone with her the majority of the time because she is still needed quite a bit of assistance with her basic ADLs. She would also qualify for a short stay in subacute rehabilitation if you wanted that as well. She would not qualify for acute rehab because she did not meet the medicare requirements for acute rehab. The main criteria being she only had one joint replaced, she is of normal weight, and was stable in regards to her few chronic medical conditions. 

Options upon discharge after knee replacement.

After talking it over with your husband, you decide that you think you can take an additional week off of work and stay with her at her house. Her therapists felt that she would likely be able to progress to a modified independent level with her basic ADLs within this timeframe. The case manager makes arrangements with a home health agency that you chose. Her home health initially was only going to include PT, OT and a nurse, however, the case manager advised you go ahead and request a home health aide to assist with non-medical issues.

Just before your mom discharges, she is seen by the surgeon who examines the surgical site (closed with staples) and then redresses the site. There was just a small amount of dried blood around the wound. The surgeon informs you that the surgical site looks just as she would expect and that she would like to see your mom in 2 weeks for her post-op visit. In the meantime, the dressing can be changed daily or whenever it gets soiled. Your mom is not to get the wound wet in the shower so must wrap it to keep it dry. Assuming it is healing as expected, the staples will come out at the follow-up visit in two weeks. The surgeon tells her she can remain on the scheduled Tylenol, use the ice packs frequently, and she writes a prescription for a few tablets of the Tramadol to use only when her pain gets to at least an 8 out of 10. 

A range of emotions can be expected after knee replacement.

You are a bit nervous about what is to come in the next week, but you feel good about the decision to take her home. On your way home, you are comforted even more because you already get a call from the home health agency to set up her evaluation for the next morning. You are relieved that the knee replacement surgery is over and are now looking forward to your mom getting back to her active life!

Please leave a comment if you have a question or experience to share about joint replacement. What do you wish you would have know prior to knee replacement surgery?

© 2020 Jessica Kluetz, DO