Total Knee Replacement
Guidelines after Total Knee Replacement surgery
Congratulations on your new Total Knee Replacement (TKR)! I am excited to guide you through your recovery as you begin to regain your active lifestyle. This document will attempt to help you through your recuperation with activity guidelines, as well as answer some of the most common questions that patients have after undergoing this procedure.
By the time you have left the hospital/rehab facility, you should be able to get in-out of bed by yourself, walk with the cane, and go up and down stairs. The biggest challenge in the early recovery of a TKR (up to 3 months postoperative) is the regaining of knee motion.
We will send a physical therapist to your house to help you with the walking, knee exercises, and gentle manipulation of the knee. The therapist will likely come to your residence 2 to 3 times per week. On the days that the therapist does not come, it is still important for you to continue walking and performing your exercises. Most patients will continue to need the cane for walking until I see you in the office at 6 weeks postoperative.
As soon as your home therapist feels that you are ready for outpatient PT, please call my office and we will supply a prescription for you. I do not want there to be any gaps in your physical therapy regimen.
I recommend that you walk as much as your feel comfortable (at least 2-3 times a day), trying to walk a little further each time. You may walk inside or outside as you feel comfortable. As stated above, you will need a walker or cane for stability for the first 6 weeks. When you begin to felt that you don’t need the cane anymore, you can begin to wean from the cane; that is, you can stop using it for short distances and walk progressively more without it.
For the first several weeks after TKR, you will likely go up/down stairs one foot at a time (non-reciprocally). The pattern to follow is: “Up with the good leg, Down with the bad (operated)”. As you get stronger, I encourage you to try to climb stairs alternating one foot per step; holding on to the banister will help. It is easier to go up first, rather than down because climbing down stairs requires more strength.
Knee motion is extremely important to work on during your recovery. Scar tissue begins to form immediately after surgery, and if the knee doesn’t regain its motion within a set amount of time, it will continue to be stiff. You must work on both extension (straightening) and flexion (bending) of the knee.
For extension, I recommend placing a rolled-up towel under the heel of your operated leg, in an attempt to suspend the knee like bridge. Then, perform a quadriceps contraction to press your knee downward, in order to straighten the knee. Hold for 10 seconds, and then repeat. I recommend doing this exercise 10 times per hour!
For flexion, I recommend sitting in a chair and bending your operated knee as far back as possible. You can use your other leg to help push the knee to bend more. If you are going home directly after the hospitalization, I may have prescribed a CPM device to help you with flexion. Use the CPM for 4 to 6 hours a day, divided between 2 applications, in order to increase your bending. Your goal for flexion is to bend beyond 90 degrees within 2 to 3 weeks of surgery.
It is typical to need pain medicine regularly during your recovery from TKR (sorry!). Typically, powerful medications like Percocet, Vicodin, Norco, Dilaudid, or Endocet are used initially. Most patients require a steady regimen of narcotic pain medicine while in the hospital or rehab facility. Once you get home and further out from surgery, you may try to wean from the pain medication, as there are many side effects of taking narcotics. I suggest that you try decreasing the amount of pain medication or increasing the interval between doses in order to wean from the medication during the day. You may have to try different methods to see what works best for you. Most patients will continue to need to take pain medication prior to physical therapy sessions for 8 to 12 weeks postop.
You may also try less powerful pain medications such as Ultram, Nucynta, or Tylenol #3 if you are experiencing a lot of side effects and your pain isn’t too severe.
Please call my office well in advance of running out of pain medication. I can only call in a 5 day supply over the telephone, so it is better to call us and have a prescription mailed to you so that they will be able to dispense a greater supply.
Your knee will be swollen for several months following TKR. I advise using ice packs regularly during your recovery. In the first few weeks, you will probably need to ice your knee 3-4 times per day; after about 1 month, it may be only at night; after 2 months, it may only be after physical therapy sessions. As the healing progresses and your knee gets stronger, your swelling will diminish.
It is also common to experience swelling below the knee, into the calf. Most times this is a result of gravity (standing on your feet and walking). This type of swelling should go away in the morning if you elevate your leg at night. Wearing a compression stocking that goes above the knee can also help. If the swelling in your calf persists despite elevation, please call my office to have this checked.
You need to continue taking the prescribed blood thinner until I see you in the office again. This is to prevent the development of blood clots.
The early exercises for the TKR consist of the following, and should be done by performing 5 sets of 10 through the course of the day:
- Ankle pumps
- Quad sets (pressing the knee down)
- Gluteal squeezes
- Bending the knee by sitting in a chair/using the CPM
Later exercises should be done in the same fashion and include:
- Limited straight leg raises (do not do this with any weights)
- Pushing the operated knee to bend more with your other leg, while sitting
- Placing the operated leg on a stair/step and leaning into the knee (to increase the bend)
- Riding a stationary bicycle (without resistance) – you may have to put the seat higher so that you can turn the pedals all the way around
- Walking and exercise in a pool, after 3 weeks
My best advice to you during your recovery is to listen to your body – that is, if you overdo it on one day, you may have more pain in the knee the next day.
Please call my office to make a followup appointment at 6 weeks post-operative to see one of my physician assistants. We will obtain x-rays of your new knee and go over the plan to continue making progress.
Frequently Asked Questions:
When can I shower?
You will have completely cover the staples before showering, or wait until they are removed (10-14 days postop). You can wrap the incision with saran wrap or other water-resistant dressing and tape the edges to keep the incision from getting too wet. Do not immerse the incision under water for 3 weeks postop.
When should I go to outpatient therapy?
As soon as you feel able to go to outpatient PT, or your home therapist tells you that you are ready, I’d like you to call my office so that we can get this started. It is important not to have any gaps in your therapy regimen. I like outpatient PT as soon as possible because there is more equipment to help get your knee bending.
When can I drive?
You should not drive as long as you are taking narcotic pain medication regularly. For most patients, this would be about 6 weeks postop. You can ride in a car as a passenger before then, however.
I feel "clicking" inside the knee, is this normal?
The clicking is a result of the artificial parts coming into contact with one another. This sensation can be unnerving at first, but is totally normal for TKR.
There is a numb spot on the side of my knee, next to the incision, is that normal?
Yes, this is normal after TKR. There will be patch of skin on the outside of the knee, next to the incision, that has diminished sensation to the touch. This generally gets smaller and smaller as you recover, but there will likely always be a numb patch around the knee.
Can I work out in the gym?
You can go to the gym and resume upper body workouts, as long as the knee is in a non-loaded position (you should be sitting, not standing, when using weights).
When can I return to work?
It depends on your occupation. It is never a mistake to take more time off in the beginning of your recovery, as it will give you time to focus on your knee. I recommend taking at least 6-8 weeks off for a single TKR, and 8-10 weeks for a double. Keep in mind that you may still be using a cane and it may be difficult to commute.
When can I go to the dentist?
Please wait until 3 months after surgery, as the knee is still healing and there is increased blood flow to this area.
Can I travel?
In general, I like to see you before you fly. If you are traveling by car, you should be sure to take frequent breaks so that you don’t feel too stiff when getting up. On an airplane, I like you to wear compression stockings (if within 6 weeks postop), and take a couple of walks during the flight. Having an aisle and bulkhead seat will help you get more space.
When can I kneel?
Kneeling will be painful for several months after TKR. It may take up to 1 year postop to regain the ability to kneel, and you should always kneel on something well-padded.