Total Knee Replacement: What to Expect After Discharge Home – ATX Orthopedics Austin, TX

WHAT TO EXPECT AFTER TOTAL KNEE REPLACEMENT:

DAY 0-1:

RE-HYDRATE!  WATER/ELECTROLYTE DRINKS!

REBOUND PAIN WHEN THE SPINAL WEARS OFF.  IF you are not having pain, you don’t have to take the narcotics given – stop narcotics if you’re having nausea/vomiting/dizziness.

Occasionally,  FOOT DROP (unable to move foot upward) can happen if the numbing medicine from the nerve block leaks around a nerve in the back of the knee.  THIS RESOLVES WHEN THE NUMBING MEDICINE WEARS OFF – USUALLY BY THE NEXT DAY.

YOU START THE MULTI-DRUG PAIN PROTOCOL.

YOU START YOUR HOME EXERCISE PROGRAM:

FIRST 2 WEEKS – FOCUS IS RANGE OF MOTION and SWELLING MANAGEMENT NOT STRENGTHENING:

THE LEG AND THE KNEE SWELL FOR 14 DAYS and then intial postop swelling plateaus.  DO NOT POKE THE BEAR!  NO FORMAL PT ADVISED DURING THE immediate POSTOP SWELLING PHASE!

Mitigating the Post-operative Swelling Tsunami in Total Knee Arthroplasty: A Call to Action

EVERY HOUR WHILE AWAKE SHOULD INCLUDE:

40 minutes of ICING and ELEVATION (TOES ABOVE THE NOSE). ICING CAN BE DONE 24/7 AS LONG AS THE SKIN IS PROTECTED FROM FREEZER BURN.  THIS SHOULD BE DONE 40 minutes per hour the first 10-14 days postop.

Flexible ice packs or Ice machines with a bladder are commonly used by patients.  They are not covered by insurance and need to be purchased online.

 

 

 

FUZZY WALE COMPRESSION STOCKINGS are used for 14 days to decrease swelling of the foot and ankle when patients are awake – they can be removed at nighttime. They are not covered by insurance and need to be purchased online.  www.compressiondynamics.com

 

 

 

EDEMA/SWELLING MEDICATION/SUPPLEMENT:  DIOSMIN daily for 6-8 weeks postop. (RECOMMENDED IF YOU HAVE VARICOSE VEINS/SPYDER VEINS/ANKLE OR FOOT SWELLING/VASCULAR DISEASE) – BUY ONLINE HERE)

 

 

AT HOME EXERCISES:

• 10 ankle pumps per hour                                                                       

 

 

• 10 passive/active-assisted knee EXTENSIONS (straightening) with 10 knee FLEXION (bending) exercises in a chair (HEEL SLIDES) per hour.  A towel under the foot can help decrease friction from the floor. FLEXION GOAL is 90 degrees by 7 days.

 

• 10 steps per hour of WALKING WITH A WALKER              Step count LIMITS:
  • 750 steps/day maximum WEEK 1
  • 1200 steps/day maximum WEEK 2

 

 

 

• 3X/DAY 10 MINUTES PER EXTENSION BLOCK (set a phone alarm reminder) (aka HEEL DROP or HEEL PROP) – WHERE YOUR KNEE IS UNSUPPORTED, BY PROPPING YOUR ANKLE UP ON PILLOWS OR A TOWEL OR A COFFEE TABLE.

 

 

DAY 1-5:

SWELLING AND BRUISING OF KNEE, THIGH, CALF, ANKLE AND FOOT.  THE AMOUNT OF SWELLING AND BRUISING VARIES FROM PERSON TO PERSON – EVERYONE RESPONDS DIFFERENTLY  – THIS IS NORMAL.

PAIN IN THE BACK OF THE KNEE APPEARS 12-18 HOURS POSTOP WHEN THE POSTERIOR NERVE BLOCK WEARS OFF – A LOT OF PATIENTS REPORT CALF PAIN AT THIS TIME – THIS IS NOT A DVT (DEEP VENOUS THROMBOSIS), THIS IS THE POSTERIOR BLOCK WEARING OFF.

ONCE THE POSTERIOR CAPSULE BLOCK WEARS OFF, YOUR PAIN INCREASES SLIGHTLY AND THEN DECREASES OVER 12-24 HOURS.  YOU ARE NOW AT A STEADY STATE.

DAYS 5-8:

(IF ON-Q BALL PUMP USED) BLOCKS WEAR OFF AND ARE DISCONTINUED.  There is an increase in pain when the 2 blocks wear off — this lasts less than 24 hours and then you reach another steady state.  At this point there are no more expected spikes in pain.  Pain and swelling are DIRECTLY RELATED TO ACTIVITY LEVEL – 40 minutes of ICING and ELEVATION (TOES ABOVE THE NOSE) per hour.

DAY 7: 

OK to remove dressing and leave open to air.  The Steri-Strips (white tape) across the incision will fall off on their own – if still on, they can be removed after 3 weeks postop.  OK to shower with the wound uncovered now, using Hibiclens soap over the incision in the showers (NO SUBMERSION OF THE WOUND UNTIL SCAB GONE – USUALLY 3-4 WEEKS POSTOP).

DAYS 7-14:

Depending on fitness level, WALKER is discontinued, continue to use of cane if limp is still present.

• Step count LIMIT:  1200 steps/day maximum WEEK 2

AFTER 2 WEEKS, PHYSICAL THERAPY (PT) can either be:

1. SELF-DIRECTED using instructions (Home Exercise Program ie HEP)

1. FOCUS ON RANGE OF MOTION (ROM) – 5-8 minutes of range of motion exercises 6x/day
2. Elevation and icing of limb 30-40min 3x/day at minimum, more if needed.
3. Isometric quadriceps sets in full extension, no isotonic or closed kinetic chain strengthening until 6 weeks post-op
4. Step count LIMITS (you do not have to meet these counts – they are limits):
   1. 2000 steps/day maximum WEEK 3
   2. 2750 steps/day maximum WEEK 4
   3. 3500 steps/day maximum WEEK 5
   4. 4500 steps/day maximum WEEK 6
   5. IF desired, ok to progress by 1000 steps/week in each subsequent week letting pain/swelling be the guide.

2. Outpatient PT  (OPPT)

ALL STUDIES SUGGEST YOUR KNEE FUNCTION/OUTCOME DOES NOT RELY ON FORMAL PT, but on you doing the Home Exercises.

 

FAQs:

• SLEEP DISTURBANCE/INSOMNIA?

Common after joint replacement surgery – your body is activated! due to the trauma of surgery (your SYMPATHETIC NERVOUS SYSTEM ie “Fight or Flight” response) – this elevated sympathetic tone causes difficulty with sleep and also restless legs occasionally.  Zolpidem (Ambien) can be prescribed if desired to help with the insomnia.

• KNEE SWELLING WITH ACTIVITY LASTING MORE THAN YOU WANT/EXPECTED!?!?!

YES.  As above, related to your INDIVIDUAL SYMPATHETIC nervous system response, which DILATES blood vessels causing increased blood flow to the leg and knee, and therefore swelling (THINK HIGHWAY OF BLOOD TO YOUR LEG AND KNEE INSTEAD OF A COUNTRY ROAD).  This swelling persists, depending on activity level and YOUR UNIQUE SYMPATHETIC TONE.  This is probably the most frustrating part of your knee replacement recovery.  It is possible that it can take 9-12 months for your knee to stop reacting to high activity level by swelling.  Diosmin/Hesperidin supplements have been shown to be helpful in addressing this swelling.

• DENTAL CLEANINGS? Avoid for 6 MONTHS postop.  As above, the HIGHWAY of blood to your KNEE is at 6 months a COUNTRY ROAD again – so lower risk of mouth bacteria from a cleaning going to your knee.

Written by Sean Gallagher, MD, Board-Certified Orthopedic Surgeon, Fellowship trained in Hip and Knee Total Joint Replacement