Total Knee Replacement: Your Guide From Pre-op Through Recovery An Evidence-Based Approach

By Neil Snyder

Has it been recommended that you or a loved one undergo a total knee replacement? Do you have questions or concerns about what to expect? You are not alone. I have written this easy to understand guide to total knee replacement surgery based on twenty-three years of clinical experience and from the evidence in the research for a successful outcome. You will learn about arthritis and the different approaches to symptom management before surgery. A detailed plan is outlined to prepare you, your support system, and your home prior to surgery. This is followed by a description of what to expect the day of the surgery and during a typical hospital stay. Topics include; ongoing and effective pain control, therapy and nursing care, unlikely post-op stumbling blocks, stress and anxiety management, and discharge planning. A timeline of healing milestones allows you to customize and advance therapeutic exercise and walking programs to optimize results and minimize setbacks. Family members will find this book is an excellent resource to guide their loved one from pre-op through recovery. You will feel empowered by the knowledge of the most current research on total knee replacements and physiological principles to minimize pain, inflammation and improve healing to confidently navigate through this journey. It is also highly recommended for all members of an orthopedic program to develop evidence-based treatment interventions and discharge plans for the total knee replacement patient.

• Language: English
• Publisher: Neil Snyder
• Release date: Jan 8, 2021
• ISBN: 9781637609057

Book preview

Total Knee Replacement:

Your Guide From Pre-op Through Recovery

––––––––

An Evidenced-Based Approach

by

Neil Snyder, PT, DPT

To my loving wife, Cheryl, who has been by my side, supporting and encouraging me to be the best version of myself. I love you. To my beautiful daughters, Jordan and Avery, I love you both very much.

To my colleagues, I thank you all for inspiring and supporting me through this endeavor.

A very special thanks to my mentors and friends, Robert Post, PhD and Carl Deirmengian, MD for putting me in a position to create and share this book with patients and  other healthcare providers.

Contents

Foreword       vii

Introduction      ix

1 Knee Pain      1

2 Before Committing to Surgery   7

3 Preparing for Surgery    15

4 The Day of Surgery     29

5 Post-op      40

6 Hospital Stay and Preparing for Discharge 62

7 Unlikely Post-Operative Stumbling Blocks 72

8 Early Recovery     85

9 Aftercare      88

10 Remainder of Recovery    98

11 Putting It All Together    111

References      122

Index       135

About the Author     139

Foreword

As a hip and knee replacement surgeon at the Rothman Orthopedic Institute in Philadelphia for 15 years, I have had the opportunity to care for thousands of patients making the difficult decision of whether or not to have a joint replacement.  My efforts and interest in research, to identify improved methods of caring for patients, led to my work with Neil Snyder, the author of this book.  Our collaboration since the start of my practice has included caring for patients together, conducting research together, and working on committees to optimize a regional joint replacement program.

Dr. Snyder has a quite sophisticated understanding of the breadth of difficulties among patients having a joint replacement, as he is intimately involved in their post-operative care, not only guiding their therapy, but also having prolonged conversations with each patient while administering therapy.  He understands their concerns, anxieties, misconceptions, and pains at a level that positions him perfectly to write this book. Most unique about Dr. Snyder is his clear passion not only in caring for patients, but also in providing care that is based on evidence as opposed to tradition.  His work in research, reviewing literature, and decision-making for our joint replacement program has been substantial.

This book fills a long-standing void in the references available to those embarking on the voyage of a joint replacement.  From the patient’s point of view, information gathering leading up to and through a joint replacement is an incredibly difficult endeavor. The barriers to attain accurate information include 1) misinformation among family and friends,  2) misinformation spread among advertising in health care 3) the complexity of several topics in the field, and 4) the anxiety patients have while trying to remember things explained during a short surgeon visit.  In fact, it is well known in healthcare that patients forget much of what is explained or taught during an office visit.

Dr. Snyder provides a simple, straightforward, and comprehensive review of joint replacement surgery which will greatly enhance the experience of anyone having a joint replacement. In this book, he addresses the most common misperceptions, simplifies the most complex topics, and

educates the reader on the most important aspects of having a joint replacement surgery. It is important for the patient to find a surgeon that they feel comfortable with and develop a communicative physician/patient relationship. Hopefully, this book will reinforce that relationship, providing a background and context which can focus those interested in having a joint replacement on the topics that are truly important for the patient’s outcome.      

— 

Carl Deirmengian, MD 

The Rothman Institute

Associate Professor of Orthopaedic Surgery

The Lankenau Institute for Medical Research

Director of Arthritis and Joint Replacement Research

Introduction

I am fortunate to work with a team of healthcare providers devoted to the highest quality of care and advancing the field of total joint replacement.  Unfortunately, outdated treatment interventions and myth engrained in all aspects of care before and after surgery still exist.  Patients have legitimate concerns because of what they have heard from previous patients, friends or family members.  Some interventions surrounding this surgery are passed down from surgeon to resident and therapist to student based on tradition and routine without any scientific basis.  This erroneous information is shared with patients creating additional, unwarranted stress and anxiety making recovery more challenging. 

Total Knee Replacement: Your Guide From Pre-op Through Recovery supplies you with evidenced-based research to help you make informed decisions and ask focused questions to optimize your care. It reviews arthritic pain and explores non-pharmacological and pharmacological pain management strategies before committing to surgery. A clear plan is outlined for the weeks and months before surgery, as well as, what to expect the day of surgery and each day until discharge from the hospital. You will learn about the most common, but statistically unlikely post-operative stumbling blocks patients encounter. Also, Total Knee Replacement: Your Guide From Pre-op Through Recovery covers the first two weeks post-op until complete recovery by identifying key components to address each week and

month post-op as you achieve specific healing milestones. This evidenced-based approach will provide you with the knowledge to customize your recovery, minimize setbacks, and give you the best results possible.

1

Knee Pain

It is a familiar story. Your knee pain has been going on for weeks, months, or years.  Morning pain and stiffness decreases during the day only to return by the evening. You deal with some, if not all of these symptoms: swelling, warmth, cracking or grating noises with movement and weightbearing, decreased flexibility, changes in shape, size, or angular deformity (bow-legged or knock kneed) of the knee.

Getting in and out of chairs, walking and climbing stairs are painful.  A cane or walker has become a necessity.  Activities of daily living (ADL) like bathing, dressing, and stepping in and out of the bath tub are labor intensive.  To put on socks and shoes requires technique modifications, while managing instrumental activities of daily living (IADL) like driving, cooking, housework, laundry, and shopping, require adjustments.

Eventually, you reach your threshold and make an appointment with your primary care physician.  The doctor examines your knee and gives you a prescription for an x-ray and physical therapy.  If you have arthritis, x-rays will show decreased space between the femur (large bone of your thigh) and tibia (shin bone) where cartilage has worn away. Also, arthritis may appear under the patella (knee cap) and the trochlear groove (small groove on the femur where the patella glides with movement of the knee joint). Your x-ray may also show extra bone called osteophytes or bone spurs that have grown along or within the joint. Baker’s cysts are common as well. They commonly develop behind the knee and cause excessive fluid to build up resulting in swelling and pain.  

You attend physical therapy two-to-three times per week. Your therapist instructs you on basic knee exercises to increase strength, flexibility, and maintain the health of the joint.  Several weeks pass with minimal or no improvements and you often find the pain is worse following PT sessions. You follow up with your primary care physician to re-evaluate the knee and express your frustrations. Your doctor recommends you see an orthopedic surgeon for another opinion.

This visit with the surgeon goes as follows. He or she examines your knee(s), looks at the x-rays, reviews your information, and asks how your knee pain impacts your ability to ambulate, climb stairs, perform transfers and self-care tasks. The surgeon makes it clear. Based on your symptoms and PT results, you are a candidate for a knee replacement.

Bad news. No one wants surgery. Thoughts of having surgery ramp up your anxiety and stress making it difficult to think clearly and ask questions.  The surgeon may offer an injection in the knee joint for some temporary relief (I will review the research on injections later on).  You leave the doctor’s office, mind racing.  Am I ready for this surgery?  Is there something I can do to delay it?  If I lose weight will the pain go away?  What should I do before the procedure?  Do I need additional tests before surgery?  What happens during the hospital stay?  How much pain will I have?  How long will I be in the hospital?  How much physical and occupational therapy will I need?  Will I go to rehab after my hospital stay? Will I need homecare or outpatient physical therapy?  Do I need a walker or a cane? Do I need a commode  or shower chair?

You are not alone in your concerns and anxiety.  Despite knee replacement being one of the most common procedures in the world, stress and anxiety remain.  As with any surgical procedure there are stories about patients having bad experiences, ongoing pain, not achieving full range of motion, pain and torture dished out by the physical therapist, and even serious complications.  Take a deep breath.  Calm your mind and body.  Negative stories are