Total Knee Replacement Guide

The Post-Operative Course

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Will I Need Help at Home?

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• We anticipate that you will be able to take care of your basic needs when you get home from surgery.  However, your surgeon recommends that you have a caregiver before, during, and following your surgery who will be able to help you with certain tasks and will also be available to arrange transportation for you to and from the hospital and to and from appointments.

• Caregiver participation before, during, and after hospitalization will help promote a smooth recovery.

• Once you get home, your caregiver will provide emotional and social support and will also help you with your exercises, assist with meal preparation and housekeeping, and assist you with your personal care needs as needed.  

• A caregiver can be a family member, a friend, or a person you hire.

• If family members are flying in from out of town to help you, they shouldn’t need to stay for more than 2 weeks.

• If you would like to hire a caregiver, the case managers can assist you in making arrangements.

  • This should be arranged BEFORE your day of surgery.

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Changes in Blood Pressure, Temperature and Skin after Surgery

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• During the first 10 days to 2 weeks after surgery, it is not unusual to experience fluctuation in blood pressure.  This is your body’s way of responding to the stress of surgery.  Blood pressure can be low at times or higher than your baseline.  This will settle down over a couple of weeks.  If it is consistently high, you should call your internist / primary care physician for recommendations.

• Temperature can fluctuate as well.  As long as your temperature does not exceed 101.5°, you should try Tylenol to reduce it.  

  • Make sure you do not exceed 4000 mg of Tylenol in a 24 hour period (less than 3000mg is ideal).

  • Many pain medications (Percocet, Vicodin, Norco, etc.) contain 325 mg of Tylenol, so please take this into account when calculating your Tylenol intake.  

  • A temperature DOES NOT automatically mean you have an infection.  

• Inflammatory changes, including redness and warmth, affecting the skin around the incision are normal and expected for weeks after surgery especially after activities. 

• Redness, heat, pain, swelling, and a low-grade fever following surgery ARE NOT always indications of an infection.  

  • If you have concerns about these, please call your surgeon’s office at (808) 522-4232, NOT your internist.  

  • Doctors unfamiliar with normal post-operative changes may misinterpret these as signs of infection and prescribe antibiotics.  

• DO NOT TAKE ANTIBIOTICS DURING THIS TIME UNLESS SPECIFICALLY TOLD TO BY YOUR SURGEON (NOT YOUR PCP OR OTHER DOCTOR)

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Bruising, Swelling, Weight Gain, and Frequent Urination

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• Bruising of the leg is normal following knee replacement surgery.  

  • The bruising is usually in the back of the leg and/or inner thigh and can extend from the knee to the foot.  

  • Bruising is at its worst 2 weeks following surgery.  

  • Please do not become alarmed if you notice bruising developing during this period.  

  • Although it can look dangerous, it is generally not to worry about and will resolve on its own.

• Swelling of the leg is normal.  

  • You will notice that the amount of swelling you have will increase in the few days after you get home.  

  • This is because you will be up on your feet more than you were in the hospital.  

  • Gravity will pull the fluid you’re retaining down into your leg.  

  • The operative leg may be 1 ½ times the size of the other leg.  

  • The best way to reduce the swelling is to elevate your leg as high as you can any time you are resting.  

  • The more of a downhill slope you can create, the faster gravity will pull the fluid out of your leg.

  • Try to have your ankle higher than your knee and your knee higher than your hip.  

  • It is okay to put a pillow under your knee if you find it more comfortable to elevate your leg this way.

  • Some patients find it helpful to use a “wedge pillow” to elevate their leg.  

    • This can be purchased at most medical supply stores.

• Patients frequently report that they weigh 8-12 pounds more in the days following surgery.  

  • This is due to the extra fluid you are retaining (the swelling in your leg).  

  • Your weight will return to baseline once the extra fluid is filtered out of your body.  

• As your swelling subsides, do not become alarmed if you are urinating more frequently.  

  • This is your body’s way of eliminating the extra fluid.  

  • It does not mean you have a urinary tract infection.

• Most of the swelling should resolve in the first 4 weeks after surgery but may take up to 12 weeks.
   

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Pain Management

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• Post-operative pain is the result of inflammation from the procedure and changes in activity level as you heal.  

  • Inflammation generally takes the form of pain, swelling, redness, and heat (especially after activities).  

  • A normal post-operative knee will continue to be inflamed to some degree for up to approximately 12 weeks following surgery (the early healing period).  

  • Inflammation from the surgical procedure itself usually peaks about 3 days after the procedure.  

• It is important to be aware of this because most patients are discharged from the hospital while the inflammation curve is still on the rise.  

  • This means you will have more pain and swelling in the few days after you get home than you did in the hospital.  

  • This is normal and expected. 

• You should take your pain medication as needed.  

  • As stated in the in-patient pain management section, it is important to take your pain medicine before your pain becomes unbearable.  

  • The sooner you take the medication, the more effective it will be.

• Do not be stoic and try to “grin and bear it”.  It is more important to manage your pain so you can be more active.  

  • Again, the goal is not to make you pain free, but rather to have a baseline pain score of about 3-4.  

• In order to manage your pain effectively in the first few days at home, you may need to increase the frequency of your medication.  

  • If needed, pain medication can be taken every 4-6 hours.  

  • Again, the key words are “if needed”.  

  • You should not take pain medicine before you need it (pain less than 3 or 4) as this will increase your chances of experiencing side effects. 

• Please be aware that you should not take narcotic medications on an empty stomach.  

  • Always make sure you’ve eaten something before taking pain medicine so you reduce the chance of nausea.  

• Please do not be overly concerned about becoming addicted to the pain medication.  

  • Multiple studies have shown that patients generally do not become addicted to pain medications in the immediate weeks following joint replacement surgery. 

  • However, prolonged usage (weeks) can lead to dependency.  The goal is to have you off the narcotic pain medicine by approximately 2-3 weeks if possible.

• Most of the inflammatory pain and swelling you experience will subside in the first 4 weeks from surgery.  

  • You will find that your pain medication needs will taper naturally as you recover.  

• You should be taking Tylenol from the day of surgery and ultimately may taper off the narcotic medicine, so you are only taking Tylenol.   

  • Make sure you are not taking more than 4,000 mg of Tylenol in a 24 hour period as this may lead to liver toxicity (less than 3000mg is more ideal).

• Please be aware that most narcotic pain medications contain about 325 mg of Tylenol (acetaminophen), and factor this in when calculating your daily Tylenol intake.   

  • Please do not take Advil, Aleve, ibuprofen, or any other anti-inflammatory while you are on as-pirin unless instructed.  

    • Your blood may become too thin.  

  • Celebrex is okay to take concurrently with aspirin.   ​

  • Once you are finished taking the aspirin (4 weeks after surgery), you may take anti-inflammatories as needed.

• It is normal to have a “rocky” recovery course.  

  • You will have good days and bad days.  

  • As you continue to recover, you will have more good days and the bad days will taper.

• You may have inflammatory set-backs as your activity level changes.  

  • These, while uncomfortable, are not dangerous.

  • You will need to slow down, ice and elevate your leg diligently, take your pain meds as needed, and sometimes go back to using an assistive device like a cane or walker until the inflammation subsides.  

  • An inflammatory flare can occur any time during the initial 12 weeks following surgery and may still occur even further out from surgery with prolonged or "aggressive" activity.

• A useful tip is to increase your walking distance in as step-wise fashion.  

  • Since it takes about 3 days to feel the effects of inflammation, increase your walk in 3-day increments.  

  • If you can walk the new distance for 3 days comfortably, you can increase it on the 4th day.  

  • See the activity level section below for more details.

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Activity Level

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• We want you to be active after surgery in order to promote good blood flow and build new muscle memory.  

• Once you get home, you should not stay in bed all day.  You should resume your daily routine as your comfort allows.

• You should begin a regular walking program.  

  • Start by walking 5-10 minutes a day.  

  • Every 3 days, you should increase your time or distance as comfortable.  

  • By 3 weeks from surgery, you should be walking 15-20 minutes outdoors comfortably.  

    • By this point, most patients are walking without a cane indoors and only take the cane with them on outdoor walks in case they encounter uneven surfaces or feel fatigued.  

    • You can continue to increase your walking distance as your comfort and endurance allow.  

• Make sure you increase your activity level gradually, and do your hospital exercises twice a day.  

  • Your knee will initially be stiff from the swelling.

  • As your swelling subsides, your motion will get easier.  

  • Most TOTAL KNEE patients are bending their knee about 85-90 degrees by 4 weeks AND PARTIAL KNEE patients are bending approximately 110 or more by this point.  

• Keep doing the exercises and the motion will continue to improve.  

  • The majority of your range of motion progress will be made in the first 12 weeks, but you will continue to make gains for 12 months. 

• Patients who play tennis or golf are usually able to resume these activities once the knee is healed—about 12 weeks from surgery.  

• Please do not engage in excessive activity (18 holes of golf, singles tennis, difficult hiking, resistance exercises) in the first 12 weeks as this will increase your swelling and slow your range of motion progress.

• Please do not use a treadmill for your walk until you can walk 1-2 miles outdoors comfortably. 

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Physical Therapy/Mobilization 

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• The key to rehabilitating your knee is walking.  

  • As described above, you should start a walking program immediately post-operatively.  

  • Walking will help you with your gait pattern, your balance, coordination, stamina, and strength.

  • The more you walk the better physical condition you will be in.  

  • Please remember to increase your time/distance gradually.

• You can start working on motion exercises immediately after surgery.  

  • The key to regaining your motion without increasing your inflammation is to do exercises that are low intensity and very rhythmic (many repetitions). 

• Using a stationary bike without resistance is another option.  

  • For an upright bike, put the seat as high as it will go.  

  • For a recumbent bike, put the seat as far back as it will go.  

    • You will not be able to make a full revolution initially, but practice going back and forth and you’ll quickly progress to full revolutions.

• There are a number of exercises you should do daily.  

  • They are included HERE.

  • Do them TWICE a day every day after surgery including days you do physical therapy.

• Generally, a prescription for outpatient therapy will be given to you and set up prior to your surgery but formal physical therapy for a total knee replacement is not always required.

  • If you can take a walk daily and can do some basic exercises, you may not need formal therapy.  

• We recommend "home exercises" for the first 2 weeks and then starting formal outpatient therapy thereafter. 

  • Having someone aggressively push on your leg to get your knee to bend can be very painful and very counterproductive.  

  • It will only result in increased inflammation and swelling and will result in further stiffening of the knee and potential problems with the wound. 

• Generally, a physical therapist can work with you 2-3 times a week for about 4-6 weeks for a total knee as an outpatient.  

  • See “Total Knee Replacement Post-Operative Physical Therapy Protocol” at the end of this page.

• We want you to focus on walking and the basic home exercises during the first 2 weeks.  

  • You may use a stationary bicycle as described above if you wish, but the bicycle should not be a substitute for your walk.

• You may use a treadmill but walking outdoors is preferred.

• You may start lower extremity resistance training 6 weeks after surgery but this should start slowly.

• Only begin "return to normal / higher level" activity around three months from surgery.

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Icing

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• You should apply cold for at least 30 minutes 4 times a day initially for the first week.  

  • The more you use cold therapy, the more quickly your inflammation will subside.  

  • We recommend utilizing cold therapy any time you’re resting.  

• You should continue to ice after activities (i.e. daily walk, exercising, running errands) and before going to bed for at least 3 weeks following surgery.

• Regardless of the type of cold therapy equipment you have, we recommend using a towel or washcloth between the cold pad and your skin.  

  • If you’re using ice packs, make sure you ice for no longer than 30 minutes at a time and allow a period of 30 minutes to lapse between applying ice packs.

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Blood Clot Prevention

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• As stated above, you will go home with medication to keep your blood thin and will also have compression stockings to wear.
  Take your aspirin, persantine, Coumadin, OR alternative medication as directed.  It is important to continue for 4 weeks following surgery.

• Make sure you are being active at home and not resting in bed all day.  Again, activity keeps the blood flowing.

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Driving

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• Driving can be resumed when you feel ready to get behind the wheel and when you are not taking narcotic pain medications regularly.  

  • This is approximately about 2 weeks for a left knee and 3 weeks for a right knee.  

• When you feel ready to drive, sit in your car for a few minutes and practice moving your foot from the gas to the break.  Make sure this is comfortable for you.  

• Do not drive unless you can stop the car immediately.

• YOU MUST CEASE NARCOTIC PAIN MEDICATIONS FOR AT LEAST ONE DAY PRIOR TO DRIVING.  

  • If you are involved in an accident while on narcotic pain medication, you may face criminal charges even if the accident was not your fault.

• The first time you drive, only drive a short distance and make sure you have someone with you who can take over if you find you’re not quite ready.

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Sleep and Energy Level

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• It is normal to have difficulty sleeping in the first 12 weeks from surgery.  Several ideas may help:

  • Find a comfortable position to sleep in.

  • Take pain medication 30 minutes before going to bed.

  • Ice for 30-45 minutes before going to bed.

  • Warm milk may help you relax.

  • If you do these and still have trouble sleeping, you may try taking Tylenol PM.  It’s okay to take 2 if needed.

• It is normal to feel tired or fatigued for the first 12 weeks following surgery.  

  • This is because your body is expending a lot of energy trying to heal.  

  • Most patients find that they need to take a nap in the afternoon.  

  • If you feel tired, you should rest.

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Nutrition

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• It is very important to get good nutrition following surgery.

• You may not have much of an appetite for the first few weeks after surgery, but you should still make sure you are eating enough fruits, vegetables and protein.  

  • You need to provide your body with the building blocks it needs to heal.

• We no longer recommend taking an iron supplement following surgery.  

  • Iron can increase your risk of post-operative constipation.  

• Make sure you drink enough fluids, as the pain meds can be constipating. 

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Constipation

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• Constipation is not unusual following surgery.  It is a consequence of taking narcotic pain medications and having a reduced activity level.

• To prevent constipation, make sure you drink enough fluids.

• Add a fiber supplement to your diet—Benefiber, Metamucil, and FiberCon are options.

• Eat berries, kiwi’s, dates, prunes and/or prune juice.

• If you become constipated, add milk of magnesia to the above.  Take as directed.

• Add a stool softener to your daily medications—Colace is over-the-counter.

• If these are not effective, we recommend Miralax—over the counter bowel stimulant.

• If you’ve tried all of the above and still are not able to have a bowel movement, get a bottle of magnesium citrate—also over-the-counter.  

  • Drink the whole bottle with 2 glasses of water.  

  • It should work within 3 hours.

• If you’ve tried all of the above and have not successfully had a bowel movement, please call your PCP for additional options.

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Bathing and Dressing Changes

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• Change your dressing daily starting on the second day after surgery and keep your wound covered for 2 weeks following surgery UNLESS you are specifically told to keep your dressing on longer (for example - PICO dressing). 

• Once this initial dressing is removed, you can cover your wound with a simple gauze and tape dressing.  

• You do not need to put Betadine or any other disinfectant ointment over the incision if you need to change your dressing.  

  • Use regular body soap.

• You may shower as per your usual routine starting 2 days after surgery as long as your wound is not draining and there are no open spots.

  • You should remove the gauze and tape dressing prior to showering and replace it with a clean dry dressing after the shower.  

• After approximately 14 days, you may leave the incision/wound uncovered as long as it is not draining or there are no open spots.  

  • At this point, you may shower without a bandage on the incision.  It’s okay to get the incision wet but do not scrub it.  Dab it dry when you are through.

  • If the wound is draining still or open, you should keep it covered and your surgeon should see the wound.​

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Bath, Jacuzzi, Swimming Pool

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• Do not immerse the incision in a bath, Jacuzzi, or swimming pool for 3 weeks following surgery.  

• If you have any doubt about the extent of healing, please wait until you have come in for your post-operative appointment and we have evaluated the incision.  

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When Do I Come to the Office for Check-Ups?

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• If you do not already have a post-operative appointment, please call the office at (808) 522-4232 and schedule an appointment for 2 weeks following surgery.  

• This should be arranged by the nursing staff prior to leaving the hospital.  If you do not have a confirmed appointment on your discharge paperwork, please call for an appointment as soon as you get home.

• If you are doing well at your post-operative visit, you will not need to return for further follow-up until the 6 week mark.  

  • After that, we will see you at 6 months and 2 years.

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