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 hospital will provide a walker for you to bring home upon discharge.
Where will surgery take place?
Dr Mullen has operating privileges at multiple hospitals, but for many reasons he prefers to do inpatient knee replacement surgery at Banner Baywood Medical Center.
All of his patients get a private room. This is not the case for every doctor there.
All of his patients are cared for by a certified orthopedic nurse who will not concurrently have responsibilities for any patients with concomitant infections or contagions. This is very important to Dr Mullen and should be to you. Within this system, there are very few resultant infections.
The physical therapy program targets and allows for patients to be discharged usually within 1-2 days. Hardly ever is a Rehab Center or a Skilled Nursing Facility necessary with his program there.
Banner Baywood contracts with almost every insurance plan, as do the anesthesiologists.
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. You will be provided packages of Hibiclens and an instruction sheet at the Hospital Pre-Op appointment. Please shower the night before and the morning of surgery with the 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 hospital?
You will report to the hospital about 2 hours 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 spinal anesthetic. This allows for both better postop pain control as well as less nausea and a lower complication rate than a general anesthetic. If a spinal anesthetic is contraindicated for some reason, the anesthesiologist will discuss your options with you to make an informed and consensual plan. Regardless of the type of anesthesia, 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 60 to 90 minutes in the Recovery Room. Your guests will visit with you only after you leave the Recovery Room and are brought to your private room.
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. Once in your room oral pain pills will be available to you every few hours as needed.
Let Dr Mullen 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 pill 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 Femoral Nerve Block immediately after surgery. This ‘block’ will numb the nerve in your upper thigh that supplies sensation to a large part of your knee. This minimizes pain, wears off within 12-20 hours, and will leave your leg feeling very ‘heavy’ until it wears off.
Do I walk on my leg right away?
Yes. The day of surgery! After getting settled in your room you will get out of your bed and walk with supervision using a hospital supplied walker. Dr Mullen will have you scheduled for two sessions of PT the day after surgery. One after breakfast, and the second after lunch. Your goal will be to walk 50 to 100 feet down the hallway with your walker during both sessions.
When will I go home?
Some patients with commercial insurance may be allowed to go home the same day as surgery. This is not the norm, and as of 2015 ‘same day discharge’ is not yet even allowed by CMS for Medicare patients. As such, most patients will stay at least one night, and some stay two nights. Most patients are home by the second day after surgery. Rarely is it necessary to stay longer than that. It is even more rare to need to go to a Rehab Center or a Skilled Nursing Center instead of to your home. Banner Baywood is a lovely hospital but remember, you are not sick. When you are mobile enough to get in and out of bed, up from and back into a chair, and up and down the hall, you should plan on going home.
Wouldn’t it be safer to stay longer or go into Rehab?
Not necessarily. Studies have shown an increase rate of infections and medical complications in patients who stayed in the hospital longer or went to Rehab. But you will not be discharged to home until Dr Mullen feels that it is safe and after you have passed three evaluations: Dr Mullen’s evaluation from the surgical perspective, the hospital assigned IPC medical doctor’s from the medical perspective, and the evaluation by your physical therapist.
How will I manage at home?
A team is assembled to help you. Usually the next day and always within 36 hours of discharge, the Home Health Team will be at your house. Dr Mullen will arrange for a physical therapist to visit with you 3x/week for two weeks and a registered nurse to check you 2x/week for those same two weeks after you get home. If you don’t have one, the hospital will provide you with a front wheeled walker to go home with.
Do I get a "Motion Machine"?
CPM or Continuous Passive Motion machines are not used in the hospital for the first few days after surgery. This is partially to allow you to rest. Once you go home however, a CPM 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. Sequential Compression Foot Pumps are used when not walking while in the hospital. 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. You may shower and get the incision wet, but only let soapy water run along the incision briefly before 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.