After Your Patient's Knee Replacement

Advice for the primary care setting

Many of you will see patients after a total knee replacement (TKR) and wonder, "Does this wound look normal?" "Should he still be limping?" "Shouldn't she have more motion by now?" "Why is he still on pain medication?" "Should she be walking around on that?" "When are those staples coming out?" This article is intended to provide a general appreciation for the pathways of rehabilitation after joint replacement -- what to expect, what not to assume, and when to contact the surgeon.

Surgery Basics
You will find that many patients who have undergone knee replacement have common threads to their complaints. Rash, pain, swelling, bleeding, discharge, stiffness, numbness - these may all be described by patients after surgery.

If orthopedics is not your specialty, you might not know exactly what your patient has been through, or know where they're headed. Let's start with the basics to provide an idea of what you might reasonably expect to see in the TKR patient.

To give you some context, knee joint replacement surgery, often called total knee arthroplasty or total knee replacement, is not a small surgery. Depending on a number of variants, including surgeon, patient, prostheses and unexpected complications, the surgery can take anywhere from 90 minutes to several hours . and longer if complications arise.1 TKR typically requires a 3- to 4-day inpatient stay, during which time the patient receives analgesia, anticoagulation therapies, physical therapy and occupational therapy. Surgeries are usually preceded by preoperative clearance or optimization of chronic medical conditions from primary care, but sometimes also by an anesthesiology-supervised team or clinic (often called preadmission testing, preoperative clinic, etc.). During this preoperative evaluation, the patient's chronic conditions will have been tuned up, medications adjusted for optimal health and outcome, and expectations/course of rehabilitation thoroughly discussed. But for most primary care providers, the knowledge base often ends here. What happens to your patient after they enter the operating room, and how does it influence their postoperative course?

Demands on the Patient
Setup and positioning itself can be physically demanding on the patient. Manipulation of the knee, hip and/or ankle for positioning and stability can occur even before an incision is made, and patients, especially older ones, can end up with bumps, bruises, sore hips and thighs from positioning and tourniquet placement. Ankles can be sore because they are sometimes manipulated or held in place to keep the knee flexed for surgical cuts.

A surgical prep solution is used on the patient's skin, often a betadine or povidone-iodine combination. Sometimes a patient develops a contact-type dermatitis in response to the surgical prep cleanser used in the OR. Reactions of this type can manifest in any kind of single-leg rash, lesions or hives from toe to mid/upper thigh, but they usually stop abruptly at tourniquet level (beyond which the surgical prep is not used). Tape allergies also can manifest postoperatively, and they may appear as a fairly well-defined strip or block of skin irritation.

Nausea and vomiting for the first 24 to 48 hours is a common reaction to anesthesia, and it does not necessarily mean that the patient is allergic to the oral pain medications prescribed after surgery. Persistent nausea or vomiting, however, should be brought to the attention of the surgeon's clinic, since a change in medication may be helpful. Itching is a common side effect of narcotic medication and generally does not require treatment - merely toleration and perhaps the addition of an antihistamine.

During the joint replacement, surgeons use saws, drills, hammers, rongeurs and all manner of soft tissue retractors to eliminate unwanted osteoarthritic bone and protect ligaments by pulling them out of the way. Such tension on ligaments and soft tissues may cause bruising, swelling and soreness for several weeks after surgery.

Nerves can be irritated during surgery or compromised by postoperative swelling. A little residual peri-incisional numbness is to be expected, but persistent or bothersome symptoms should be brought to the attention of the surgeon.

On the day of surgery, it is common for patients to at least sit and dangle the surgical leg over the bed. Most patients begin ambulating with assistance on postoperative day 1 or 2. Physical therapists and occupational therapists typically make daily hospital visits to each joint replacement patient, to outline a plan of progression as recommended by the surgeon. Except under unusual circumstances, most surgeons discharge their patients at 3 to 5 days postop, when they are medically stable, ambulating with a walker or other assistive device, and cleared by PT/OT.

Some surgeons prescribe the use of a continuous passive motion device (CPM machine). This is a machine that fits onto the patient's leg while reclining. It gently moves or rocks the knee joint back and forth, allowing flexion at the hip and at the knee, to facilitate the return of motion after surgery. The surgeon recommends flexion and extension limitations for the CPM machine, if used. Some patients have a home CPM unit and are typically given instructions for where and how to set their machine to provide gentle progression of motion on their own. For any questions about the settings for flexion and extension on a CPM machine, the surgeon's office should be contacted to confirm the plan of progression for each patient.

Wound Care & Pain Management
Wound care after hospital discharge varies by surgeon practice, but in general sutures or staples will be removed by either home health or the surgeon's office sometime in the first 2 weeks following surgery. Wounds that show increasing or persistent drainage or bleeding and require more than simple bandage changes once daily after discharge from the hospital should be evaluated by the surgeon's office.

Pain can be difficult for the nonsurgeon to assess after a TKR. Pain after joint replacement is influenced by many factors, including pain prior to surgery, stiffness, hematoma formation, generalized swelling, length of surgery and any complications encountered. Some patients are pain free within the first 2 weeks after surgery, but it is more common to have continuing, albeit improving, pain that gradually dissipates over the initial 6 weeks. Some patients are content taking acetaminophen, others require some narcotic coverage over the first couple of months, gradually decreasing in strength and frequency.

The surgeon's office is usually better positioned to manage postoperative pain medications, and will monitor the patient's progression for any unusual signs, including pain that is unexpected given the course of the patient's surgery. It is best to bring persistent pain complaints to the attention of the surgeon's office.

Preventing DVT
Deep-vein thrombosis prophylaxis is an issue under continuing review in orthopedic circles. Your patient may be on an injectable or on an oral anticoagulant. Some surgeons prefer to withhold chemoprophylaxis due to risk of bleeding. Some require monitoring with labwork and adjustments in dosage (such as warfarin) and others do not (such as rivaroxaban and aspirin). Some patients are put on anticoagulants for a few weeks and others for a few months. If your patient is not on an anticoagulant or does not seem to have proper monitoring set up, contact the surgeon's office for clarification or additional recommendations.

Ambulation and stiffness are other variants in rehabilitation following joint replacement. Physical therapy, although not prescribed by all surgeons, is a common part of the postoperative rehabilitation course. Restoration of motion and strength are primary goals of therapy, since a stiff knee will be painful and interfere with normal stride. A great resource for you to see the kinds of exercises a patient may be asked to do at home can be found at http://orthoinfo.aaos.org/topic.cfm?topic=a00301.

And finally, what can you and your patient look forward to after a successful joint replacement? If all goes well, patients will experience decreased pain, increased functionality and a return to a higher quality of mobility than they experienced previous to the surgery. Higher impact activities, such as running, skiing, etc., are

likely to lessen the life of the prosthetic joint and thus are typically not recommended, but walking, swimming, cycling, golf and other low- to non-impact sports are certainly within acceptable expectations. The patient's surgeon will have specific recommendations about return to sport and normal activity, based on the patient, the surgery and the prosthetic. Although some patients return to full function by 3 months, progress can still be made at 6 months, 9 months and even a year. You can help your patients recover from TKR by reminding them that arthritis took a long time to get to the point where it required a replacement, and that the process of regaining their motion, muscles and activities will also not occur overnight. We should all be looking for progress,  not perfection.

When should you worry? If your patient runs a fever, has active drainage or pus coming from their wound, or has persistent severe pain or swelling in spite of true elevation (reclining, with knee at or above the level of the heart and ankle above knee), he or she needs to see the surgeon's office right away. Emergency department visits are also required for signs or symptoms of a deep-vein thrombosis or pain that is simply yet urgently not controlled with oral medications. Postoperative pain management should be handled through the surgeon's office or by agreement with another provider who understands the surgeon's expectations for pain.

Don't be afraid to contact the surgeon's office for patient follow-up. The operative note is sometimes helpful, but it may not contain a patient plan. However, most recent visits to the surgeon will typically contain progression of motion limitations, any restrictions and descriptions of wounds at last visit. A quick call to the medical assistant staff at the surgeon's office can be an easy way to confirm what the patient should - and should not - be doing.

The more you know and understand your patient's surgery, they more he or she will appreciate your care. The patient will be confident that you have coordinated care and expectations with their surgeon, and will feel more cared for because of your team approach.

Resources you may find helpful:

General information on Joint Replacement from the American Academy of Orthopedic Surgeons: http://orthoinfo.aaos.org/topic.cfm?topic=A00233

More information on activities after Knee Replacement: http://orthoinfo.aaos.org/topic.cfm?topic=A00357

This article's content was distilled from information found on the American Academy of Orthopedic Surgeons website (http://www.aaos.org/). To access additional information, click on Patient Information, Knee and Leg, and Joint Replacement.

Other information was obtained from: Tomek IM, et al. Innovation profile: a collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Aff. 2012;31(6):1329-1338.

Jennifer Van Atta is a physician assistant who specializes in orthopedics at Mid-Columbia Medical Center in The Dalles, Ore. She has completed a disclosure statement and reports no relationships related to this article.


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