Must Know Knowledge: Total Knee Replacement (Arthroplasty) Surgery

As learned in our previous blog posts on understanding surgeries (see: rotator cuff, knee scope), we used to work alongside surgeons. One of these surgeons completed A LOT of joint replacement surgeries – almost entirely on the knee and hip.

Therefore, we’ve treated our fair share of post-operative clients – especially post-knee replacement! As an FYI, a total knee arthroplasty (TKA) is science speak for a total knee replacement (TKR), so they are used interchangeably!

      So you’re going to have your knee replaced… The purpose of this blog post is to try and clarify the ins and outs of having a knee replacement surgery.

Knowledge is power! Be prepared, and things will go smoothly!

     Aside: We will use the same headings in this post as we did in the other ‘Must Know Knowledge’ posts.

We’ll try to stick with the same format so that it’s easier to navigate. Some things might look similar, as some advice is “surgery” related, and less specific to the type of surgery.

How do I know if I even need a total knee arthroplasty (replacement)?

Typically, to qualify for a knee replacement, many, or all, of the following statements are true:

  • You have significant knee pain that is greatly limiting your ability to complete your activities of daily living (i.e. walk, sleep, work), including pain at rest
  • You have imaging results (i.e. an x-ray or MRI) that show significant arthritic changes or knee joint/cartilage damage
  • You have significant inward or outward bowing of your leg
  • You have long standing knee swelling/inflammation that doesn’t improve with rest or conservative treatment
  • You have tried to reduce your pain and improve your function through virtually every other conservative option, including a significant bout of physical therapy
    • Conservative options include, but are not limited to: physiotherapy, massage therapy, chiropractic care, acupuncture, over the counter medications, and injections

Do I have to do pre-operative physiotherapy? In short, yes, you should. It helps in the following ways:

  • Helps you understand what to expect with surgery and postoperatively (just like this blog post should!)
  • Helps strengthen muscles to their maximum potential (not just knee muscles, but also ankle, hip, and core muscles)
  • Improves your range of motion to help limit stiffness in all associated joints
  • Can help you gather baseline measurements to track your progress post-op (scientifically, there are indicators of who will continue to have significant pain post-surgically. Knowing this ahead of time can help your physiotherapist make more informed decisions)
  • In some cases, it can prolong the need for surgery (and to be honest, in Ontario, the waitlists for knee replacement surgery are pretty long!)

Because your next question is probably: “What are the indicators of prolonged pain?!”, here they are:

  • Catastrophizing,
  • Poor mental health
  • High levels of preoperative knee pain, and pain at other sites are the strongest independent predictors of persistent pain after TKA. [Source: Lewis, G. N., Rice, D. A., McNair, P. J., & Kluger, M. (2015). Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. British journal of anesthesia, 114(4), 551-561.]

What else should I do before I get a total knee arthroplasty (replacement)?

  • Understand what you’re getting yourself into. Seriously. This is a big one, so please read on. A total knee replacement is a BIG surgery, with a long rehabilitation period.
  • Eat well and take steps to improve your overall health (i.e. quit smoking)
  • Get any equipment that will help you get around (including equipment your surgeon recommends)
    • Examples include: a knee brace, a walker, cane, or crutches, a raised toilet seat, grab bars for the shower, a shower seat, dressing aids, etc.
  • Organize assistance from other people for after surgery (often, you’re not allowed to drive, heavy chores (grass cutting, snow shoveling) still need to be completed, etc.)

How is a total knee arthroplasty (replacement) performed? Every surgeon has their individual preferences, however, knee arthroplasty is typically performed as described here:

  • You will be in a surgical room, with many nurses, a surgeon, an anesthesiologist, and often a few other people (i.e. students, joint implant representatives, etc.)
  • The anesthesiologist will either partially or completely sedate you (put you to sleep a little or a lot), or perform an epidural (numb you from the waist down) (this is often a patient/surgeon preference/decision) – but sometimes, depending on the method, you’ll be able to hear everything going on!
  • The surgeon will perform an incision across the front of your knee – usually 6-10 inches long
  • Once access to your knee is granted, the surgeon will shave the end of your femur (thigh bone) down, shave the top of your tibia (shin bone) down, shave the back of your patella (knee cap) down so that all arthritis/joint damage is completely removed (every case/surgeon/joint prosthesis leads to variations in how much bone is removed)
  • Then, they will screw, or cement new, smooth, replacement parts onto the end of your femur, end of your tibia, and back of your patella (sometimes the patella is completely replaced)​
  • Once all the parts are replaced and all the joint damage is removed, your incision will be closed and you’ll be taken away for recovery.
  • This animation on YouTube is an average example of what generally happens:

Note on the video: not every surgeon implants the drain​

Psst. If you want to know more about knee anatomy, check out our post here: ​​​​ACL. MCL, Meniscus – My Knee Injury Sounds Complicated 

Disclaimer: Before we get into the next part of this blog post, it is important to note that everything in this blog post is for information purposes only.

This blog post is not intended to be strict medical advice. As previously mentioned, everyone is an individual, and therefore, individual variances do occur.

It is important to consult your physiotherapist, surgeon, or doctor for the most applicable advice for You.

What does the typical rehabilitation process look like?

     First, it’s important to reiterate that everyone is an individual, with individual circumstances, and therefore, the rehab process will be very individualized.

That being said, in almost every case, it is safe to walk on your leg immediately after surgery, and you will typically spend 1-2 days in hospital post-operatively.

In the hospital, you will learn how to walk with a walker, climb stairs safely, and be monitored for any post-surgical complications.

Once at home, you will often be allotted home physiotherapy appointments with a physiotherapist (for free), through the Community Care Access Centre (CCAC).

That being said, the amount of appointments provided by the CCAC has been significantly reduced in the past couple years (down to 1-4 total appointments), which is not enough.

Due to the limitation in the number of CCAC-funded appointments, you will continue with further physiotherapy via one of two options: publically-funded (OHIP) physiotherapy, or privately funded (out of pocket/private benefits) physiotherapy.

OHIP physiotherapy often has a limit to it as well, and many people require more than the “program of care” allows for.

Therefore, it is important to consider the potential financial costs of ongoing physiotherapy when undergoing a total knee arthroplasty.

This next sentence is important:

Complete rehabilitation after a total knee replacement will usually take 6-12 months.

It’s likely that someone will tell you 3 months.

3 months of rehabilitation can get you back to work (depending on your job), or allow everyday life tasks to be more easily and comfortably completed. To get back to 100%, it will probably take longer.

You may not be required to frequently attend physiotherapy appointments, but you should expect to be working on exercises, and self-management for up to 1 year postoperatively.

​Overall, post-operative care looks something like this:

  • You’ll be allowed to walk right away – you will learn using a walker, then slowly progress to a cane, then to no gait aid (providing that’s your goal!) (Aside: there is absolutely NO SHAME in using a walker or cane. Using a gait aid in the early stages will actually help you recover FASTER than trying to tough it out and not use one at all!)
  • Physiotherapy will start within 1 day of surgery (in the hospital), and within a few weeks (via an OHIP or privately funded clinic)
    • Note on OHIP-funded clinics: they’re VERY busy, so it’s often a good idea to call weeks before your surgery to set up your physiotherapy assessment for a couple weeks after your surgery (in fact, this is just good practice, even at a privately funded clinic)
  • There are likely no restrictions, so your physiotherapist will formulate an individualized program designed to:
    • Decrease your pain
    • Improve your range of motion
    • Improve your balance
    • Improve your strength
    • Get you back to the things you want/need to do!
  • Everyone is progressed on an individualized timeline!

Here’s the unfortunate part: gaining the range of motion (over the first couple months postoperatively) in your brand new knee is usually not very fun.

It’s painful.

It’s necessary.

That being said, speak openly and honestly with your physiotherapist to ensure the process is not completely unbearable, because that’s not helpful either.

How long does it take to heal after a total knee arthroplasty (replacement)?

In uncomplicated cases,

  • Surgical healing of your knee can take up to 3 months after surgery (and swelling might stick around to some degree for 6-9 months).
  • Surgical healing does not always mean full function. It means the surgical sites and joint surfaces are likely physiologically healed.
  • Full function is very individualized in the case of a total knee arthroplasty and usually takes:
    • 3-6 months to feel comfortable/confident with your activities of daily living and for return to work (longer for excessively physical jobs) (and to have the pain under control)
    • Up to 6-12 months for a complete recovery (good range of motion, full strength, full return to work and life activities)
  • Progressive, safe, and necessary functional strength training exercises will take months to appropriately complete. ​
  • Additional note: in many cases, rehabilitation post-operatively is not just helping you heal from your surgery. You’ll also be rehabilitating the months-years of poor function you had before surgery!

​​ As with any surgery, here are some additional things to consider:

  • You may be off work a long time, depending on your job (for example: if you are on your feet constantly doing a lot of squatting and stair climbing, you will be off work much longer than someone with a desk job)
  • Physiotherapy appointments will be necessary for at least 3 months (often longer). Yes, the frequency of appointments will decrease over time, but it will be important to stick with your physiotherapy appointments.
    • You can receive some physiotherapy through OHIP-funded clinics, but it’s often not enough
    • If you have private insurance coverage, that’s great! But keep in mind, depending on how much you have, it is not uncommon to use all of it, and then some.
    • If you don’t have private insurance coverage, rehabilitation costs will be expensive.
    • Couple this with being off work and finances can be a significant added stress that many people do not consider!
    • Be aware of the financial considerations associated with surgery. ​​

What exercises are safe to do right away after a total knee arthroplasty (replacement)?

     In the hospital, or from the surgeon, you will likely be provided with a list of exercises to get started on.

These usually include range of motion, and muscle activation exercises. These are a great place to start. That being said, the primary goal in the early postoperative stage is to focus on gaining flexion range of motion (knee bend).

Here’s one of the most common knee flexion exercises (called a heel slide):

A prescription of 10 repetitions with 5 second holds, 3 times a day is common when working on this ‘heel slide’ exercise.

Overall, you will progress in this order with rehab (roughly):

  1. Range of motion exercises/Pain management
  2. Strength building exercises
  3. Motor control exercises

In many cases, this order is blended, and you’ll be working on multiple types of exercises at once to ensure a slow, progressive, increase in load. For example, when trying to focus primarily on a knee range of motion exercise to improve knee flexion, you may also be working on a hip strengthening exercise (your hips help support your knees!). Your physiotherapist will help you learn an exercise program that accomplishes your goals in the least amount of time, all while trying to limit any negative feelings or complications.

     Lastly, it’s highly likely that you and your physiotherapist will work on other joints (such as the ankle and hip) together.

You should be able to work on hip musculature (which greatly supports the knee) safely, so it is highly recommended.

This should help to reduce any postoperative complications in your other joints, all while decreasing your pain, and improving your overall function!

How much function and how little pain can I expect at the end of my rehabilitation?      Alas, the loaded question. (We know we’ve started this section with that same sentence for each of the ‘Must Know Knowledge’ surgical blog posts… Sorry, but it’s always a loaded question).

Again, everyone is an individual, everyone heals differently, and therefore final pain and function are highly individualized.

As mentioned earlier in this post, there are some indications of ongoing pain after a knee replacement.

Further, if there are complications with surgery, it may alter the progress/end result of your recovery.

Here are some things we consider:

  • How much pain did you have before surgery? Was the pain just in your knee (or also in other parts of your body?), and how long did you have that pain?
    • Again, these can be related. If you were in absolute agony for 3 years before surgery, there will be a lot of additional things to consider when trying to reduce pain post-operatively. Pain has biopsychosocial components. See this awesome blog post on pain for more information: Why isn’t My Pain Going Away?
  • How is your mental health? Do you tend to catastrophize pain/injuries?
    • As mentioned, higher levels of catastrophization and poor mental health have been linked to ongoing pain after a total knee arthroplasty. That being said, your physiotherapist can help you understand pain, and what referrals can be made to enhance your overall wellbeing/recovery. (Go read that blog post about pain!)
  • What are your goals?
    • If your goal is to very active, your rehab will probably take longer than if your goal is to walk around your house and sit at your desk at work. Therefore, ​​depending on your goals, your perception of your overall function will also change.
    • That being said, set appropriate, attainable goals with your physiotherapist and work towards these goals!​​

     All that being said, the vast majority of individuals that we’ve treated post-total knee arthroplasty did very well overall, and outcomes are typically very favorable.

The caveat to this is that our experience is based on people who actively attended rehab! Remember, the rehabilitation stage after surgery is VERY important to reach a full recovery!

What are the potential complications associated with a total knee arthroplasty (surgery)?

All steps will be taken to limit complications postoperatively, however, it’s important to understand the possibilities.

Complications include:

  • Infection. It’s important to follow the hospital’s instructions on keeping your incisions clean, and free of debris. Change your bandages as instructed, and take good care of your wounds.
    • Keep an eye out for:
      • Ill-smelling, discolored discharge coming from your wounds.
      • If you’re running a fever, have a significant increase in pain, swelling, or redness around the knee.
  • Deep vein thrombosis (DVT). This is a blood clot that can form in the blood vessels of your leg. Most commonly, in the calf muscle area (but can also form in the thigh muscle area). Here’s what to look out for:
    • If your calf or thigh is:
      • Red, hot, and swollen
      • Painful to touch, and painful with bending your ankle upwards
      • Throbbing or cramping
    • These are the most common signs of a DVT. If you think you may have a DVT, go directly to the hospital. This is an emergency.
  • Joint contracture/significant stiffness
    • In some cases (usually when rehab is not being adequately completely), the knee joint will fail to reach a functional level of bending. This puts you at risk for a joint contracture.
      • A contracture is an abnormal shortening of tissues, rendering the muscle/joint highly resistant to stretching
    • If the knee significantly stiffens, and you’re unable to bend it to a functional level, there is a possibility of needing a manipulation under anesthetic, which, bluntly, means that the surgeon will put you to sleep and force flex your knee. Yes, this is necessary if you’re not getting good mobility (to avoid a true contracture). And yes, it hurts a lot when you wake up.

Final words      There’s a lot of information in this blog post. But there’s also a lot to know. Be informed, ask questions (even the hard ones), and look out for yourself.

Let us know if you thought this blog post was helpful, and we will try to post new ones outlining the helpful points for other types of surgeries!  

     Are you planning to undergo (or have already undergone) a total knee replacement?

At Strive Physiotherapy and Performance, we are committed to providing an in-depth assessment to ensure we can work together to find the best plan of action for each individual client.

Call us at 519-895-2020, or use our online booking tool on www.strivept.cato book an appointment with one of our knowledgeable physiotherapists, and they will be sure to help you understand your injury.

Take care, Tyler Allen Physiotherapist at Strive Physiotherapy & Performance

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MIKE MAJOR, PT

BSc Kinesiology, University of Waterloo MSc PT, McMaster University

Physiotherapist

Born in Lahr, Germany

Mike treats people of all activity levels and ages from weekend warriors to elite athletes. He has mentored physiotherapists across Ontario as well as worked on the Board of Directors of the Ontario Physiotherapy Association. Recently, Mike represented physiotherapists within the Pan Am/Para Pan Am Games Medical Services Expert Provider Group. Mike has also had the opportunity to work side by side with orthopaedic surgeons, allowing him to work with many people following complex and traumatic injuries. Mike also consults over 1,000 physiotherapy cases nationally. This has given him a lot of insight into what Physiotherapy looks like across Canada.    

Prior to becoming a physiotherapist, Mike served in the reserves for 9 years as a member of the Artillery in the Canadian Armed Forces. He also enjoys coaching local athletes to help improve their performance through MeFit, a local not-for-profit organization.

What Really Matters...

Cats or dogs?

Dogs.

Worst idea you've ever had?

Skiing behind a car.

Worst fad you've ever participated in?

Rat Tail

Do you have any kids?

A baby named Maverick.

Last book you read?

Together is Better: A little Book of Inspiration

Most useless talent you have?

Sewing

 

What 3 things are you bringing with you, stranded on a desert island?

A multitool, My Wife, and our baby

Biggest Pet Peeve?

A multitool, My Wife, and our baby

In your high school yearbook, you won/would have won...?

Most likely to get stuff done

What song would play every time you enter a room?

Eye of the Tiger – Survivor

 

“It’s not the size of dog in the fight, it’s the size of the fight in the dog”