Knee Replacement Surgery: What to Expect
Total knee replacement surgery is one of the most common orthopedic surgical procedures and
the number of procedures performed each year continues to rise significantly. 1 As patients
prepare for this surgery, the amount of information that they receive regarding the procedure,
hospital care, pain management, preparing their home, post-operative rehabilitation, and
overall recovery can easily be overwhelming. This blog aims to answer many of the questions
about these aspects of the surgery.
Surgery and In-hospital Care
The locations where total knee replacement is carried out have undergone substantial changes
over the last couple of decades. The average length of time that patients spend in the hospital
after the procedure has decreased significantly and many patients now even undergo
outpatient total knee replacement. 2 Many factors play a role in the decision regarding the most
appropriate setting for any particular patient’s surgery, including patient age, medical
problems, social support at home, surgeon preferences, and many others. Even outpatient
procedures can be performed in multiple locations, such as ambulatory surgery centers,
subspecialty hospitals, and regional hospital centers. Despite the trend in shortening hospital
stays in recent years, many patients still stay in the hospital from 1-3 days following surgery.
Each patient should discuss these factors with their surgeon leading up to the procedure so that
all parties understand the post-operative expectations. It is important to note, however, that
changes to the expected length of stay may be required depending on the patient’s recovery
afterwards.
For patients staying in the hospital setting for at least one night, several aspects of care are
relatively universal. Most patients should expect to begin walking with the assistance of
physical therapists and nurses on the day of surgery. There are certain circumstances that limit
the amount of weight bearing for some patients, but that will be clearly discussed with the
patients and families when needed. Patients typically use a walker to help with balance initially
after surgery and will work with physical therapists over the first few weeks to determine when
it’s no longer needed. Additionally, patients should expect to be monitored closely after the
procedure, work with their nursing team regarding their medications and pain management,
and typically have routine lab work performed the morning after surgery. Patients are also
usually allowed to eat after they have gotten settled into their hospital room, as long as they
are not too nauseous from medications. Otherwise, the time in the hospital is geared towards
some rest and recovery, but beginning the process of post-operative rehabilitation.
Discharge
Once a patient is ready to leave the hospital, decisions are made regarding where the patient
will go next. For the majority of patients, they will be discharged to their home. Some
surgeons prescribe home health nursing to come to patients’ homes after surgery for the first
1-2 weeks before initiating outpatient therapy. For other patients, however, a period of time in
a rehabilitation facility may be more appropriate. This may be a better option for patients living
alone, are older, or have more medical problems that may limit the ability to discharge straight
home. Discharge planners are employed by the hospital and will engage with patients early in
their recovery to begin planning for the most appropriate location. They also work closely with
insurance companies to ensure the proper approvals are completed if needed.
Therapy
Physical therapy following total knee replacement is arguably the most important aspect of a
patient’s recovery. Some surgeons prefer outpatient physical therapy to begin very soon after
surgery, while others prefer a period of home health nursing in the patient’s home prior to
outpatient therapy. Regardless, patients should expect therapy to focus mostly on improving
range of motion and walking ability initially. Physical therapists will provide patients with lists
of exercises to be performed at their clinic and also at home. There is quite a bit of variability
regarding the amount of therapy needed after surgery, with some patients only needing
therapy twice a week for a few weeks while others needing more frequent therapy visits for a
few months after surgery. Nevertheless, patients should approach therapy sessions
understanding that there will be discomfort involved to improve their range of motion. Once
adequate motion throughout the knee has been obtained, therapy will transition to more
strengthening activities while maintaining the flexibility that has been achieved. A variety of
techniques and equipment, such as stationary bicycles, are used to optimize recovery post-
operatively.
Pain Management
Medication
Without a doubt, the most difficult part of knee replacement for most patients is dealing with
the pain after the procedure. Although some patients report little discomfort afterwards, most
patients describe significant pain that slowly decreases over the course of several weeks to
months. Surgeons have their own preferences regarding the medications prescribed at the
time of surgery and afterwards, but some generalizations can be made. Anesthesiologists and
surgeons begin the process of pain management even before the surgery has begun and
employ multiple methods of pain control, which is termed multi-modal pain management. At
the time of surgery, patients may receive oral and/or intra-venous medication before surgery
begins in an effort to decrease the stimulation that surgery has on the patient’s nervous
system. Additionally, anesthesiologists may perform a procedure such as a nerve block to
numb the nerves around the knee as well. Intraoperatively, surgeons frequently inject
medications in the soft tissues and knee joint, which may provide pain relief lasting from a few
hours to a few days after surgery. After surgery, many different medications may be used
depending on surgeon preference. Patients should expect some combination of medicines such
as acetaminophen, narcotic pain medicines, anti-inflammatory medications (such as celecoxib,
ibuprofen, or naproxen), and muscle relaxants. One other important aspect after joint
replacement is the prevention of blood clots. In most cases, patients will be prescribed aspirin
for this reason, but other medications may be used instead. It is important for patients to know
what medication is being used for this purpose. While pain medications will be slowly
decreased after surgery, the medicine used for blood clot prevention will remain constant for a
specific period of time and should not be discontinued until instructed to do so.
Rest
Knee replacement surgery is a relatively significant procedure for many patients. Post-
operatively, patients should expect to experience fatigue, less stamina than normal, and some
difficulty performing routine daily activities. A significant amount of energy is utilized for
healing around the site of surgery, so adequate rest and recouperation after the procedure is
needed. Patients should continue to work with therapists and other medical professionals to
gauge how much they should be walking, performing range of motion exercises, and
performing other activities. The progress towards returning to all activities is different for each
patient, so consistent re-evaluation is needed since a delicate balance must be maintained
between enough rest for recovery and enough therapy to meet the post-operative milestones.
Ice
In the attempt to improve pain and swelling after surgery, many surgeons use devices that
recirculate cooled water through a pad that is placed on the knee. Some devices also
incorporate compression as part of the therapy as well. Otherwise, ice or cooled gel pads may
be used over the bandages. Either way, patients should discuss the timing and methods for ice
therapy with their nurses prior to discharge.
Elevation
Another method for controlling swelling after surgery is elevation. Many patients experience
an increase in swelling a day or two after surgery, so it is important to elevate the leg when
resting. Patients should elevate the leg on several pillows or blankets such that the knee is
higher than the hip. In addition, for the majority of the time, patients should try and keep the
pillows or blankets mostly under their heel and ankle and not behind their knee. This will keep
the knee straightened out and help to slowly regain that component of range of motion. If
patients continuously have their leg in the most comfortable position (bent slightly) with
padding supporting their leg in that position, they will likely struggle to get the leg straight in
therapy sessions. Getting the knee completely straight after surgery is equally important as
getting the knee to bend further, so this will continue to be discussed with patients after
surgery.
Recovery After Surgery
The overall recovery following knee replacement is different for each patient and can be
difficult to completely predict. Some patients feel little discomfort from the procedure, do not
require a walker or cane for very long, and get back to normal activities within a few weeks.
Most patients, however, require a few months to begin to feel that they are making significant
progress towards doing the activities they enjoy. Since so many factors play a role in overall
recovery and all of those factors are continuously changing, there is quite a bit of variability.
Patients should continue to engage with their care team, surgeon, and therapists to frequently
evaluate their recovery and any necessary changes to the plan.
Preparing Your Home
The majority of patients will not require any modifications of their home for adequate recovery
after knee replacement surgery, but this is not true for all patients. Many people are
concerned that climbing stairs after the procedure will not be possible, but therapists will assist
patients with tips and methods for navigating stairs safely after surgery. Unless someone’s
home would require going up and down stairs multiple times per day, most patients simply
minimize the number of stairs required initially. There may be circumstances, though, where
patients need to temporarily sleep on a different level of the house or in a different room. Care
should be taken before surgery to minimize any tripping hazards and provide adequate space in
tighter areas of the home since patients will be using a walker initially. Otherwise, as a
patient’s symptoms allow, performing some normal activities such as walking, cooking, getting
up to use the restroom, and going up and down some stairs is encouraged immediately after
surgery.
Conclusions
As stated above, knee replacement surgery is a significant event in many patients lives and
requires planning before, during, and after the procedure. Surgeons continuously look for
means of simplifying the process for most patients while also ensuring the greatest likelihood of
overall success. Patients should approach their procedure with the mindset of being ready to
work hard with physical therapy to regain motion, needing to deal with pain and discomfort
following surgery, and understanding that a substantial amount of time may pass before they
get back to the activities they enjoy. With the right team in support and the right mindset going
into the procedure, most patients achieve their post-operative goals on time, are satisfied with
their ultimate result, and experience a significant improvement in their quality of life.
1 Sloan M, et al. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am
2018; 100:1455-1460.
2 Tingle C, et al. Same-day outpatient TJR gains popularity, but careful considerations must be made. Orthop Today
2015;35(8):1, 10-11.