Timeline of Knee Replacement

The number of days people stay in the Hospital following a Knee Replacement has been steadily reducing. Currently, most people are able to go home the day after the operation whereas some patients ( typically operated early morning ) are able to go home the same day of the operation.

We can discharge the patient once we are sure that the patient will be able to manage at home. For this to occur, the patient should be able to sit up from a lying down position in bed, sit by the legs dangling by the side of the bed, get up form the bed, walk a bit and to be able to sit on a chair and to get up with support ( walker ). The pain should be under control and the dressing over the knee should be nice and dry. ( A few blood spots on the dressing are common ) Additionally, the patient should have used the washroom, should have passed urine comfortably, should have eaten and if there are other diseases such as
diabetes, blood pressure etc . they should be under reasonable control. There should be enough home help and the patient and the relatives should also be willing to take the patient home.

Stair climbing is optional and my advice is that only if stair climbing is needed at home, it should be practiced. Otherwise, it can be done later. It is not necessary to wait for a bowel motion before going home.

You would have been sent home with stockings on the legs . These are special stockings to prevent blood clotting in the legs. You have to wear them more or less the whole day but may take them o” at night.

The aim in the first few days ( 1 to 3 ) is to make sure that the pain is well controlled , the knee keeps moving and to avoid swelling . The operation also is a form of injury to the knee and our body needs rest to recover the knee and our body needs rest to recover.

We need only simple exercise with or without a physiotherapist. Exercise needs to be done for 5 to 10 minutes every waking hour with 2 hours of rest in the afternoon. The exercises in the first few days are the same that you have done in the Hospital.

Ankle pumps , Quads sets , SLR , sitting by edge of bed and dynamic quads ( Active Knee extension )

Keep a pillow under the heels of the legs. DO NOT KEEP A PILLOW UNDER THE KNEE. ( Elevation of the legs reduces swelling – Try to keep toes above the nose during the elevation of the leg )

Every hour – do 10 quadriceps sets – i.e. pushing the knee down on the bed with your own muscle. ( quadriceps ) In other words, you have to tighten the thigh muscles – and hold the thigh muscles tight for a count of 1 to 10. This is the basic exercise of the knee and you would have been shown this exercise before surgery and also in the Hospital before discharge.

Every hour, 5 times, you need to raise the operated and the unoperated leg, alternately, in the air keeping the knee as straight as possible. (And count from 1 to 5 )

How high to raise the leg ? – You may raise the leg as high as comfortable.

Keeping the knee as straight as possible is extremely important and you should avoid bending the knee while lifting it. Do not raise both the legs together as this may strain your back unnecessarily.

You also need to bend the knee by the edge of the bed or whilst sitting on a chair, as much as the knee would bend comfortably and then make the knee straight again. It will help to pull the toes up whilst straightening the knee. You need to hold the knee for a count of 1 to 5. Avoid sitting on a low sofa or a stool. ( Preferably sit on a chair with handles so that you can take the support of your hands to get up ).

You need to walk for just a few minutes every hour. You may walk with support as comfortable and may move from one room to the other, walk in the corridor etc. Again, the stairs are optional.

The way the surgery is performed – You do not necessarily need a dedicated physiotherapist at home. (Interestingly, all the patients who were operated just before the lockdown due to Coronavirus – have also done equally well after the operation – despite no physiotherapist at home.)

I.e. 20 min every hour spend in exercise. (The other 40 min – rest )
Spend 1/3 of these 20 mins – in walking
1/3 – in knee bending and straightening exercises
1/3 in static knee exercise and ankle pumps.

You need to take normal diet ( not too oily or spicy ) preferably home-cooked food. It is normal to have a little loss of appetite after surgery. Most people find that falling asleep is difficult after surgery. This is why we always prescribe a sleeping tablet. You can take it if required.

The amount of pain is a little variable but is not as much as once thought. We would have prescribed pain killers to be taken by all and then extra pain killers which may be taken if the knee is extra painful. If you need to take extra pain killers, that does not mean that there is anything wrong. Pain is subjective and different people get different amounts of pain. Applying ice packs, elevating leg and not to overdo exercises help in relieving pain.

We would have applied a water proof dressing on the wound. It is all right to bathe, but one should avoid getting the dressing excessively wet. It is normal to see some skin discoloration and ecchymoses around the knee especially on the inner side. ( these would all settle over 4 to 6 weeks)

Essentially you would be doing the same things as in the first three days but more easily and with greater vigour and for greater time as tolerated . You may also add some hip exercises to your routine . The basic hip exercise is sideways leg raise.

You should lie on your side with the operated keg underneath and bent at 30 degrees. The other leg is kept straight. Now the unoperated leg is to be raised in the air by 30 degrees from the hip. Hold for a count of 1 to 5 and do 10 repetitions. Now you lie down with the unoperated leg below and keep the operated leg straight. Now you can do 10 sideways leg raise of the operated leg.

You may start going outside your home , in the compound etc. You may still avoid stairs unless necessary and avoid low seating . Sitting on the commode is generally OK.

The dressing does not require changing until you are seen again at around 2 weeks form surgery.

The need for a dedicated physiotherapist is not necessary. If you follow the exercises that we have outlined and do them well, you will not need a physiotherapist at home. Remember that a knee operation is also a form of injury to the knee and you primarily require rest. It is normal to have more pain on some days than others. You may take the extra painkillers as required. It is also normal to have some lack of sleep and some loss of appetite. Interestingly , all patients who had been operated before lockdown have done equally well without dedicated home physiotherapists

General
If one feels out of breath, has pain in the chest area or feels excessive uneasiness, or the level of consciousness drops or feels paralysed or any other major problem – one needs to contact the hospital urgently and may need to be readmitted.

Knee related :
If there is excessive bleeding or oozing from the wound or the leg appears misshapen, or you are not able to walk the way you had started walking after the operation, then also one may need to seek medical help.

Kindly note the numbers for urgent medical attention-

Recovery from 2 weeks to 3 months

You would have had a visit at around 2 weeks time from the operation to see us. Hence, any further questions and doubts could be tackled at that time also.

In general , the level of exercises can increase as tolerated , one may start going out of the house for small errands or for work. One should also start ones’ routine now and not wait for “ full recovery “ and postponing things. Here , the underlying principle is to try normal activities gently , slowly , repeatedly as tolerated until happy. Obviously , if there is undue discomfort or pain , you need to stop.

Most people by this time would be at 60 to 80 % of their recovery.

There will be occasional episodes of pain and swelling but they would reduce. If there were ecchymoses around the knee , they would be settling . You may still wear stockings for excessive swelling . You will also feel some areas of numbness around the knee and burning etc from the knee . This is normal and would reduce over 6 to 12 months . If burning is very intense , we can prescribe medicines for it.

Please be very sure that the knee is fully straightening and do not keep a pillow underneath the knee . If it is not happening , you may need special exercises to achieve that.

Most people would also be back at work by this time . Some discomfort around the knee , heaviness , a feeling of something artificial is very common and most patients would be complaining of this . Some patients also find that their appetite and sleep are still disturbed but is getting better. Almost all patients would be walking for 20 to 30 minutes by this time relatively easily. ( subject to physical ability and the state of the other joints ) Stair climbing, if not done earlier, is also started and practiced.

You would have had a visit at around 2 weeks time from the operation to see us. Hence, any further questions and doubts could be tackled at that time also.

In general, the level of exercises can increase as tolerated, one may start going out of the house for small errands or for work. One should also start ones’ routine now and not wait for “ full recovery “ and postponing things. Here, the underlying principle is to try normal activities gently, slowly, repeatedly as tolerated until happy. Obviously, if there is undue discomfort or pain, you need to stop.

Most people by this time would be at 60 to 80 % of their recovery.

There will be occasional episodes of pain and swelling but they would reduce. If there were ecchymoses around the knee, they would be settling. You may still wear stockings for excessive swelling. You will also feel some areas of numbness around the knee and burning etc.. from the knee. This is normal and would reduce over 6 to 12 months. If burning is very intense, we can prescribe medicines for it.

Please be very sure that the knee is fully straightening and do not keep a pillow underneath the knee . If it is not happening, you may need special exercises to achieve that. Most people would also be back at work by this time . Some discomfort around the knee , heaviness , a feeling of something artificial is very common and most patients would be complaining of this. Some patients also find that their appetite and sleep are still disturbed but is getting better. Almost all patients would be walking for 20 to 30 minutes by this time relatively easily. ( subject to physical ability and the state of the other joints ) Stair climbing, if not done earlier, is also started and practiced.

The complications can be General ( a”ecting the whole body ) or local ( related to the Knee )

The General complications can be a heart attack, embolism, stroke etc. Depending upon the severity, even deaths have been reported after a Knee Replacement. Obviously, as we screen the patients well the likelihood of this kind of a complication is very low.

The local complications can be infection, instability, loosening, fracture, dislocation, complications related to the knee cap, muscle-tendon rupture etc. Again the likelihood of these complications is very low in experienced hands. When a partial Knee Replacement is carried out, there are added risks of the progression of arthritis in the other urn-replaced compartments or of dislocation of the mobile bearing. ( in Oxford replacements ) Again,
even this risk is small.

The modern knee Replacements are designed for long term function from 10 to 20 years or even more. However, as in all things mechanical some maintenance is required. At least once in 3 years, the operated Knee should be X-rayed to ensure that the replaced joint is looking OK on the x-rays. As it is a replaced knee, any problem with the knee will initially manifest with X-rays, even before any symptoms develop. Apart from this, the knee is to be used but not to be abused. By that is meant, that the knee is to be used judiciously.

This is the time to gradually get back to “ normal “. This is not normal before the operation but “ normal “ before arthritis. the patients may exercise their knees, hips, walk and diet to become healthier. They may go out for walks, enjoy nature, see movies, dramas, visit religious places, shrines or whatever they fancy. They may go out of the city as well.

They can continue the gentle exercises for the knees and the hips for better toning of the muscles and better gait.

Obviously, each patient is different and each patient’s requirements are also different. The aim here is for the patient to get back to their desired quality of life. However, it is still not uncommon for patients to complain of pain, especially at night. If the patient is able to walk properly and bend the knee well then probably there is nothing wrong. However, if there is the consistent complaint of pain, investigations including aspiration of the knee ( inserting
a needle in the knee to withdraw some fluid ) may be required to rule out infection.

You would be advised to follow up at 2 weeks, 6 weeks, 3 months, at a year and then every 3 years from the operation. Obviously, if there is need you can follow up at any time. It is important to maintain optimum weight and to have a healthy lifestyle. Also, it is advised to have the knee X-rayed once in 3 years. If an actual physical follow up is not possible, a virtual follow up can also be done.

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