By Kaplesh Kumar
INDA New England Columnist
As the first arrivals to this country from our community have recently aged into their Boomer retirement years, many have undergone total knee replacement (TKR) of one or both knees. Due to the increased immigration during the late 1970s and beyond, the number of individuals requiring total knee replacements will continue to increase as the later immigrants too approach their golden years. Unfortunately, little information exists to guide a prospective surgery patient from a patient’s perspective on what to expect and how to facilitate one’s post-surgical recovery for greater benefit.
We are fortunate to have in our area several excellent surgical centers for knee surgery. Besides my own positive experience at Boston’s Brigham and Women’s Hospital, where I underwent TKR surgery this past May, I personally know people who have had successful outcomes from operations performed at New England Baptist Hospital (NEBH), Mount Auburn Hospital, Beverly Hospital, and the Lahey clinic. A decision to undergo surgery, however, should not be taken lightly and other less intrusive avenues, such as physical therapy and cortisone shots should first be explored. In most cases, however, where significant osteoarthritic deterioration has occurred (resulting in bone-on-bone contact and unbearable pain from years of neglect), such intervention may only delay the time when one commits oneself to the operating table.
Besides performing due diligence before surgery by navigating the web, it is always a good idea to get some input from friends and acquaintances, who have undergone knee surgeries, on their experiences with particular surgeons and hospitals to narrow down the available choices in the area. Although I did not get a second opinion, I do advise getting one after the first surgery recommendation. Surgical dates appear to be available anywhere from 4 to 8 weeks after one decides to get operated upon. The surgeon typically requires a pre-evaluation of the patient and his or her attendance of a class at the hospital for an overview of the expected experience, at which time the nursing staff recommends certain exercises to the patient for a more favorable outcome from the surgery.
The surgery is scheduled generally two to four weeks after that visit, which, unless the patient has dutifully followed an athletic regimen for a long time (despite the ongoing pain), is not sufficient time to properly get in shape for the procedure. The required exercises are widely available on the internet and one is well advised to download those and start training from the moment it appears one may need to go under the knife. Pre-surgery physical fitness goes a long way in making the recovery, which can otherwise be an extended and painful process, much more manageable and of shorter duration.
The surgery itself lasts about one to one-half hours. Depending on the surgeon’s preference, the patient could be placed under general anesthesia or immobilized using epidural or spinal procedures in combination with sedation. While the former can render patients nauseated, the latter treatments are better tolerated. Following the surgery, the patient is brought into his or her room for further recovery and observation under the care of the nursing staff. The typical hospital stay is two to three nights. During this period, the patient is generally constipated from the treatment, but this condition gradually relieves itself over the next several days. Upon discharge from the hospital, the patient can transfer to an inpatient rehabilitation facility or, more preferably, is sent home to recover. Where there is family support, home recovery is the better option as it also eliminates the likelihood of picking up infection from other patients at the inpatient rehabilitation facility.
Where the surgery is performed in the morning hours, the hospital’s physical therapist may visit the patient that same afternoon or the next day. The patient is made to stand up, and is encouraged to take a few steps using a walker with four support legs. Depending on the patient, the following day the patient could be provided crutches for increased mobility and made to walk nominal distances of tens of feet. The patient is trained to negotiate stairs, up and down, and evaluated for how much the patient is able to bend the operated-upon knee from a fully extended position. The important goals at the hospital for the post-surgical physical therapy, prior to discharge, include imparting basic skills to the patient for the required functionality at home.
There is little to no pain the first day of the surgery, likely because of the freshness of the injury and the pain control medication in the body. The pain intensity increases gradually over the following days and is managed using orally ingested narcotic medication. It is advisable to stay on the narcotic medication for the first week or two so as to ensure that the pain does not impede the initial recovery. Laxatives and stool softeners must be taken to reduce the constipation. It is a good idea to take advantage of the reduced pain at the hospital and increase one’s operated-upon knee’s range by bending it frequently as much as possible as one lies in the bed. The therapist shows the way to the patient, but the latter must follow it up for therapeutic benefit.
The hospital prefers that with sufficient applied pressure, the patient’s knee bends at least 90 degrees before being discharged, an achievable goal so long as the patient actively engages in therapy and does not depend exclusively on the therapist. To avoid blood clotting, some hospitals used to provide the patient with tight fitting tube-like socks to be worn for the length of the operated leg during the awake hours, but that practice has been discontinued by many (most?) surgeons as a nuisance not justified by any significant benefit.
Most of the recovery happens at home over a period of three to six months, and in some cases even longer – up to a year. Preparation of one’s home for the initial recovery period is important as the patient is not able to adequately bend the knee or lift the foot far off the ground, which requires a pain-free lifting of the leg and bending of the knee. Any obstructions in the way of the patient negotiating around the house should be removed, as should be carpets so they do not get entangled with the walker or crutches which can result in the patient falling over and injuring the recently operated upon knee.
The patient must avoid all instances of falling or otherwise injuring the operated knee, such as by kneeling or twisting the knee joint. Although the patient is trained to negotiate stairs, it is preferable if the patient does not have to do that during the first few weeks after the surgery. Depending on the patient’s ability to bend the knee, the toilet seat may need to be raised with extenders. A walk-in shower is preferred over a bath tub, as the latter requires lifting the leg to enter the tub – a particular painful exercise in the first few weeks following surgery.
The importance of icing to control the pain as the knee heals cannot be over-emphasized, both during the sleeping and waking hours as well as before and after therapy. Sufficient large sized gel packs that enclose the knee are available at medical supply stores and should be procured. While one is chilled in a freezer, a previously chilled one could be applied to the knee. The ice packs are recommended for no more than 20 minutes at a time (i.e. 20 minutes on and 20 minutes off) to avoid frost bite injury. Although narcotic pain killers are prescribed to control the pain, I feel it advisable that its intake be reduced as much as possible after the first two to three weeks by depending on ice packs and over-the-counter pain control medications, such as acetaminophen (Tylenol), ibuprofen (Advil), and naproxen (Alleve).
For the first two weeks or so, in-home therapy is prescribed with a goal to achieve a fully extended position with the operated leg, and also a knee bend angle of 120 degrees or more from full extension. The at-home visiting therapist assists the patient with settling down in the home surroundings. Here too, the therapist shows which exercises to do and how to do them, but the extent of the derived benefit is largely dependent on how aggressively and frequently the patient pursues the therapist’s directions. Therapy is a huge part of the recovery.
After two to three weeks of at-home therapy, during which the patient transitions to walking with a cane, the patient is referred to outpatient therapy, roughly three times a week, at a rehabilitation facility. This extends the assisted recovery period to a total of about three months, by which time the patient is expected to have achieved the goals of the therapy. I found a considerable benefit from supplementing the therapy with walking, in not only reducing the swelling and the pain but also building muscle mass and strength of the affected leg.
Perhaps the most difficult part of the recovery is sleeping at night. The nights can be particularly painful, often with a slight burning sensation in the leg, as one unconsciously irritates or twists the knee or attempts to climb up or down from the bed to go to the bathroom or get an ice pack from the freezer. The load of the leg on the knee from gravity aggravates the pain, but it can be adequately controlled by supporting the operated leg with one’s hands or the good leg while performing those functions.
Some patients with problems in both knees opt to get them both operated upon at the same time. After what I have experienced, I do not deem it to be advisable to do that. My recommendation would be get only one knee operated upon at a time and, at the very least, have a gap of three to six months in between the two surgeries. The advantage of going through the entire process at one shot is offset, to my mind, by the difficulty of actively engaging oneself during recovery and achieving less than optimal results, while also becoming more dependent on others for performing basic functions.
(This article represents the experiences and views of the author, and is published solely for informational purposes. Its contents should not be considered a substitute for advice on one’s medical needs, which a patient must seek from his or her doctor or therapist.)