Total knee arthroplasty, sometimes known as total knee replacement, involves the cutting and resurfacing of bone from the end of the femur (thigh bone) and replacement with a metal implant. The top of the tibia (shin bone) is also cut and resurfaced and then replaced with a metal and plastic component. The kneecap (patella) is also resurfaced.
As with any surgery, there are risks inherent with this procedure. The major risks for this procedure are the risks associated with anesthesia, risk of infection, risk of fracture, risk of phlebitis or blood clots in the legs. With Dr Mullen’s minimally invasive technique there is minimal blood loss, there is no need to pre-donate any blood, and only very rarely does a patient require a transfusion.
What do I need for surgery?
Some patients will be sent for blood work and an EKG before surgery. If a heart condition needed to be addressed within the year, a letter from your cardiologist describing your condition should be faxed to Dr Mullen.
At your office visit prior to surgery you will sign a consent form and get your prescriptions for medications that you will use AFTER surgery. Coumadin to thin your blood and a pain pill. If your insurance allows, Dr Mullen will give you a DVT Home Care kit and a knee brace with freezable gel pack, both only for use at home after surgery. See instructions on its use for DVT prevention below. The surgery center will provide a walker for you to bring home for use after surgery.
Where will surgery take place?
The SurgCenter at Pima Crossing has a program that allows for knee replacements to be done on an outpatient basis. It is located in Scottsdale off the Via de Ventura exit off the 101. It is about a 30 minute drive from Dr Mullen’s office. You can use the HOV lane with two or more people in the car to avoid traffic.
What do I do the night before surgery?
Drink plenty of liquids and do a Pre-operative Skin prep.In order to reduce the chance of infection, we ask you to perform a preoperative skin prep. Please shower the night before and the morning of surgery with Hibiclens. You may take your pre-approved medicines the morning of surgery with a sip of water, but may eat or drink nothing else before surgery. No mints, no gum, no tic tacs… nothing.
When do I need to get to the surgery center?
You will report to the surgery center about 90 minutes before the surgery is scheduled to start. That time is needed for administrative check in, escort to the preop area, changing into a hospital gown, have a nursing evaluation, get an IV, and get a preoperative IV antibiotic infusion through that IV. You will meet your anesthesiologist to both answer and ask questions. Anti-nausea medication can be delivered before surgery through the IV.
How long does the surgery take?
Once family and friends are shown to the waiting area, you will get some sedation and a motor sparing regional anesthetic. This allows for both better postop pain control as well as less nausea and a lower complication rate than a general anesthetic alone. You will not be alert during nor remember the surgery. After the administration of satisfactory anesthesia, you will be comfortably positioned and your skin sterilized. Dr Mullen institutes a series of safety checks and then will perform your surgery. That part takes about an hour. When finished, he will visit with your guests. You then will spend some time in the Recovery Room becoming more alert. When ready, you will be given a front wheeled walker and the Recovery Room team will assist you in getting out of bed and walking down the hall, putting all of your weight on your new knee! Overall, you will be at the facility for about 4 hours before going home.
How will my pain be controlled?
Your anesthesiologist will give you medicines while you are in surgery to keep you comfortable. So will the nurse in the Recovery Room. Let Dr Mullen and the anesthesiologist know if you have a preference for any particular pain medicine that works best for you. ALL narcotic pain medicine can result in nausea. This is an undesired adverse side effect, but is not an allergy. This can ideally be combatted by finding and using a narcotic that sits well in your particular stomach. If you are someone who gets nauseated with many different narcotic pain meds, we can use and anti-nausea medicine with your pain medicine or just use over the counter pain analgesics like Tylenol instead. This may be a wise strategy when the nausea of a pain pill is more distasteful than the pain itself.
Adjunctively, your anesthesiologist will give you a Regional Anesthetic, or a motor sparing ‘nerve block’ as part of your anesthesia. This ‘block’ will numb the nerve in your thigh that supplies sensation to a large part of your knee. This minimizes pain, wears off within 12-20 hours, and may leave your leg feeling ‘heavy’ until it wears off.
Dr Mullen will also inject a long acting local anesthetic into the tissues deep in the knee after he puts in the replacement but before he closes your wound. This can only numb up part of the knee, wears off slowly, but can have some effect for up to 2 full days.
Do I walk on my leg right away?
Yes. The day of surgery! After getting settled and alert in the Recovery Room you will get out of your bed and walk with supervision using a facility supplied front wheeled walker.
When will I go home? You will be allowed to go home after awake from anesthesia, comfortable, and after successfully walking down our hallway with a walker. You will also be given an opportunity to use the rest room to confirm your confidence with sitting and standing.
Wouldn’t it be safer to stay in a hospital or go into Rehab?
Not necessarily. Studies have shown an increase rate of infections and medical complications in patients who stayed in the hospital and/or went into a Rehab Center. If you are not sick and can get around safely, you don’t need to be in a hospital.
However, not all patients are good candidates for the outpatient program. For example, some insurers still don’t pay for outpatient knee replacements. And using a hospital is still a good idea if you have multiple serious medical conditions, are at high risk for complications after anesthesia, or if you are not strong enough in your arms and other leg to ambulate safely.
With this outpatient program, you will only go home when you are determined to be safe by the anesthesiologist, Dr Mullen, and the nursing staff.
How will I manage at home?
A team has already been assembled to help you. Dr Mullen will have arranged for a Home Health Company to meet with you at your house either the very next day after surgery or possibly even the same afternoon that you get home. A physical therapist will visit with you 3x/week for two weeks and a registered nurse will check you 2x/week for those same two weeks after you get home. If you don’t have one, the surgery center will provide you with a front wheeled walker to go home with.
Do I get a "Motion Machine"? Once you go home, a CPM or Continuous Passive Motion machine will be delivered to your home to use for as many as 18 days. It can be used multiple times per day and has been a device shown to help you get your Range of Motion back a little quicker. If you find it uncomfortable, it can be returned to the vendor earlier as it is not ‘mandatory’. Most patients find it helpful.
How do I keep from getting a DVT, or a ‘blood clot’?
Many things can help, but DVTs do occur sometimes. Early full weight bearing and frequent walking is the most important and effective way. You will be started on Coumadin to chemically thin your blood right after surgery.
If your insurance allows, Dr Mullen will give you a "DVT Home Care" kit at the office visit before surgery. Instructions for use, and a helpful video can be found at www.compressionsolutions.us.
Two white calf wraps are in the box that you will wear snuggly on both lower legs when sedentary at home. The white tubes emanate from the bottoms. Each wrap then plugs into the power unit under the metal clips. The power unit has to be plugged in to charge, and simply hold down the left sided power button to turn it on. The calf wraps will inflate and deflate intermittently to massage your calves and mechanically propel blood to minimize its chance of pooling and clotting in your legs.
There is a third port on the lower right side of the power unit that connects to an optional knee brace that holds a re-freezable gel pack. Some patients find this form of Cold Therapy helpful. The knee brace and the gel pack that it holds is optional. If you use it, keep the hinges on the brace unlocked. The calf wraps work without the knee brace and gel pack if desired.
When may I take a shower?
You may shower when the wound is no longer draining or spotting your dressing. That is usually the third day after surgery. If you shower before that, do so with a plastic bag or Saran Wrap around your knee to keep it dry. Only let the incision get wet once the bandage shows that the incision is dry. You may then shower and get the incision wet, but only let soapy water run along the incision briefly before rinsing and patting it dry. Keeping your incision clean this way is a good idea and can prevent infection. Do not apply any ointments or creams to your incision. You are not allowed to dunk or submerge your incision under water for 6 weeks. Water exposure in this manner can seep into the incision and cause a terrible infection. That means no bathtubs, hot tubs, Jacuzzis, swimming pools, or water therapy for 6 weeks.
When may I drive?
It is illegal to drive under the influence of narcotics. Once you do not need narcotics, and only after you feel physically able to accept the responsibilities that come with driving a car may you return to driving. That turns out to be an answer that changes patient to patient.
When will I be seen after surgery?
Your next appointment in the office is usually scheduled for 15 days after surgery.
How long will I be out of work?
Your return to work is dependent on the type of occupation you have. Patients with sedentary jobs may be able to return 2-4 weeks after surgery. Patients with a physically demanding occupation may be able to return 8-10 weeks after surgery.
Do I need to take antibiotics before dental cleanings forever now?
Dental infections or bad teeth can be a source of infection for a total knee even after the surgery is completed. For this reason it is wise to advise your dentist that you have had a total knee replacement surgery. For any dental procedures, including cleaning of your teeth, you should have antibiotic prophylaxis. This is generally a dose one hour before dental procedures. Other infections in the body, such as boils or bacterial infection, could also represent a source of problems for a person with total knee surgery. For this reason, if you have any infection you should consult your family doctor promptly so that proper treatment can be carried out.
Are my expectations realistic?
Total knee replacement surgery is major surgery and should not be undertaken lightly. It is wise to keep in mind when considering this surgery that even the best total knee replacement is not as good as your knee was when it was healthy. The goal of the surgery is to relieve your pain, if not totally, then at least somewhat. It is also the goal with this surgery that you will maintain reasonable stability and flexibility as well.
Even when you feel much better you must keep in mind that this metal and plastic knee is a mechanical device. Just like any mechanical device, including your automobile, there can be problems or failures. In general, total knee replacements can last many years. As with any medical procedure, there is no guarantee.
Even if you feel much better following your surgery it is wise that you avoid activities which cause marked flexion of the knee, high impact to the knee, or hard contusions to the knee. While permitted, they may shorten the lifespan of the knee.