Total Knee Replacement Manual

and Therapy/Rehab Protocol

Dr. Edward Kelly, MD, MBA

Burnsville:
1000 W 140th St Suite 201, Burnsville, MN 55337
Ph: 952.808.3000
Fax: 952.456.7804

Edina:
th
4010 W 65 St, Edina, MN 55435
Ph: 952.456.7000
Fax: 952.456.7804
  
You have made the decision to have a total knee replacement to decrease your pain,
regain function, and increase your quality of life. This type of surgery is a big decision
and this manual is intended to help you prepare for your surgery and guide you through
the rehabilitation process.

Getting Ready for Surgery – Check List

Get a Pre-operative Physical Exam
Before surgery, a preoperative physical is necessary. This is typically done by your
primary care physician and will need to be completed within 30 days of surgery. Bring
an up-to-date list of the current medications and supplements you are taking including
the doses of each to your physical.

Make a Post-operative Appointment

10-14 days after surgery, you will have a post-operative appointment with Lindsey
Anderson, PA-C, Dr. Kelly’s physician assistant. This appointment is typically made at
the time you schedule surgery, but if it is not, please call to schedule this appointment
prior to surgery. At this appointment, your dressings will be changed and x-rays will be
taken of your knee.

Make Physical Therapy Appointments

You will need physical therapy after surgery and these appointments can be made prior
to your surgery. Your first therapy appointment should be made for the week after
surgery. The first couple weeks following surgery you should see the therapist 2-3
times a week. Therapy can be done through Twin Cities Orthopedics or another
therapist of your choice. Physical therapy scheduling:
Burnsville: 952-808-3052
Edina: 952-456-7000

Attend Joint Replacement Class

Fairview Ridges Hospital offers a preoperative joint replacement education class. This
class gives you tips to prepare for surgery as well as goes through what to expect while
you are at the hospital and after surgery. If you will be having a family member or friend
help you after surgery we encourage you to invite them to the class as well. These
classes are a general overview of joint replacements with patients of many different
surgeons attending so the information you receive at the class may be different from
what Dr. Kelly has told you. The information you received from Dr. Kelly should always
take priority. If you have any questions about conflicting information, please contact the
office. Please visit the following website for more information about class times and
locations:
https://www.fairview.org/ServiceLines/OrthopedicsandSportsMedicine/OrthopedicMedS
urgery/jointreplacement/Jointreplacementclasses/index.htm
  
Gait Aides
After surgery you will likely use a walker, crutches, and/or a cane for an average of 2-4
weeks. These can be acquired in our Physical Therapy department. If you need
instruction on the use of these one of our Physical Therapists will be happy to help.

Stationary bike
If you have or can borrow a stationary bike, it is the very best exercise you can do for
your knee after surgery. Put the bike in a spot that will be easy for you to access.

Absence from Work

The time frame for returning to work after a total knee replacement varies depending on
you and your job. Patients who have a desk job are able to return to work on the
average within 2-4 weeks. If you have a more physically demanding job it may be 10-
12 weeks before you are back at work. If you need paperwork filled out for your
employer, please bring this to the office prior to your surgery and avoid bringing any
paperwork to the hospital. You can also mail or fax (952-456-7804) paperwork to the
office to the attention of Kaici.

Getting your house ready for your return after surgery

There are a few things you can do before surgery to make your transition home after
surgery easier. This includes moving items that you regularly use to a place that is easy
to access, having a phone that is nearby, removing any tripping hazards (throw rugs,
etc), and preparing meals for after surgery. Many patients find it most comfortable to
sleep in a recliner chair and if you don’t own one, you may consider borrowing one
before surgery. Another helpful tip is to tie a belt or rope around the inside of your car
door or other doors of your home to save you from reaching away from body and pulling
to close them.

Medications to have at Home

There are a few medications you might want to have available at home to use after
surgery if needed. These include:
§ Aspirin 325mg: This will be necessary to take after surgery to help prevent
blood clots. If you do not get it prior to surgery, you will be given a prescription at
the hospital when you are discharged. You will take one of these daily for a total
of 30 days after surgery.
§ Stool softener (senokot, Colace, Dulcolax): You may have constipation after
surgery due to being sedentary and taking a narcotic pain medication. A stool
softener can help with this as can eating a fiber-rich diet (wheat bran, fresh fruits
and veggies, oats). Other things that can help include drinking plenty of water
and getting up to walk around frequently.
§ Extra-Strength Tylenol 500mg – this is a great adjunct to the pain medication
you will be taking, as long as it does not contain acetaminophen. We
recommend avoiding ibuprofen or Aleve until you are done taking the aspirin.
  

Get an Antibacterial Soap

Developing an infection after surgery is a serious risk and there are many measures
that Dr. Kelly, Lindsey, and the hospital staff take in the operating room to prevent it.
One simple thing that you, the patient, can do to prevent infection is use an antibacterial
soap called Hibiclens. This can be purchased at any pharmacy or you can go to Ridges
Hospital after your surgery is scheduled for a free bottle. You should shower with this
antibacterial soap the day before and even the morning of surgery.

Plan to have help at home after Surgery

Most patients are able to go directly home from the hospital 2-3 days after surgery and
do not need to stay at a transitional care unit (TCU) after total knee replacement.
However, some patients, especially those who live alone and have no one who can stay
with them for a few days, those who have significant physical disabilities prior to surgery
(i.e. wheelchair or walker dependant), or those who experience post-operative
complications, may require a short stay at a transitional care facility after surgery. If you
anticipate needing this after your surgery, please let us know prior to surgery so we can
get a social worker at the hospital involved with your care early on.

Dental Appointment
Dr. Kelly recommends waiting 3 months after surgery to have any routine dental work
done. Please plan ahead and have your dental work up-to-date prior to surgery.

One Week before Surgery

§ Stop taking any vitamin supplements, herbal medications, over-the-counter

medications, aspirin, or any anti-inflammatory medications (i.e., ibuprofen,
Motrin, Advil, naproxen sodium, naproxyn, or Aleve).
§ If you take a blood thinning medication such as Coumadin, your primary care
physician will direct you when to stop taking this prior to surgery (usually 5-7
days).

Night before Surgery

§ Take a shower with the Hibiclens antibacterial soap described above.

§ Do not eat or drink anything after midnight the night before your surgery. You
can take any necessary prescribed medications with a sip of water the morning
of surgery.
§ You might find it nice to put freshly laundered sheets on your bed for you to come
home to after your hospital stay.
  

Day of Surgery
Before Surgery
Take another shower with the Hibiclens soap before you head to the hospital. Please
arrive at the hospital 2 hours prior to your surgery. Dr. Kelly will see you in the
preoperative area before your surgery to answer any last minute questions or concerns
you may have. You will also meet with one of the board certified anesthesiologists prior
to surgery. He or she will discuss different types of anesthesia, risks, and possible
complications of the anesthesia. You will have a general anesthetic and usually a local
nerve block, depending on your discussion with the anesthesiologist.

During Surgery
§ Surgery Time – The surgery will take about 1.5-2 hours. This time includes
getting you positioned, the operation itself, and waking you up from the
anesthetic after the surgery.
§ Catheter - Once you have been put to sleep, the operating room nurse will place
a catheter in your bladder to aid urination during surgery and immediately post
operatively. This will be removed the morning after surgery, once you are able to
get up out of bed to use the bathroom. Please let us know ahead of time if you
have any bladder or prostate concerns.
§ Drain - You will have a tube (drain) placed in the knee during surgery that will
allow excess fluid to drain from the knee and help keep swelling down. This will
also be removed the day after surgery.

After Surgery
Recovery Room - After surgery you will spend about 1 hour in the recovery room and
then you will be moved up to your room on the surgery and orthopedic floor. Your leg
will be placed in a continuous passive machine (CPM) the day of surgery. This machine
helps move your knee and keeps stiffness to a minimum.

In the Hospital
Pain after surgery
We work closely with the hospital staff to control your pain post-operatively. Even with
pain medications, you can expect to feel some pain. Please note that the first night you
will likely have less pain because the nerve block that was placed by the
anesthesiologist prior to surgery will usually still be in place. The day after surgery you
will be transitioned to oral pain medications. This usually consists of a narcotic pain
medicine such as oxycodone, Percocet, or Dilaudid, and an antihistamine medication
called Vistaril, which often relaxes the muscles and is a good adjunct to your narcotic
pain medications. Pain medications are opioid derivative medications that can make
you sleepy, dizzy, and constipated and doses are closely regulated by your nurse for
your safety.
  

The Incision
Your wound will be closed with sutures under the skin that will dissolve on their own,
typically after 6-8 weeks. Staples will also be placed over the incision to reinforce the
closure when you bend the knee. These will be removed at your first post-op
appointment. A bandage called an Aquacel dressing is placed in the operating room
with the intention that it will stay on until your first post-operative visit 1-2 weeks after
surgery to limit the exposure of bacteria to your incision. Finally, a soft, bulky dressing
will wrap your leg from heel to thigh and this can be removed the second day after
surgery. There may be some early drainage on the bandage which your nurse can mark
with a pen to see if it increases. Either Dr. Kelly or his PA Lindsey will see you in the
hospital before you go home and decide if the dressing needs to be changed or not.
With this dressing, you may shower over it but do not soak or scrub. The Aquacel will be
removed at your first post-op visit in the clinic and clean steri-strip bandages will be
applied.

Blood Clots
The risk of a blood clot in the the leg (or a DVT) is one of the greatest risks that we
address after surgery. To help prevent blood clots and to reduce swelling in your legs
you will be given a pair of white compression socks to wear. You should wear these
until your first post-operative appointment. You can remove these socks twice a day for
30 minutes and for showering. You will be prescribed 325mg of aspirin twice daily in the
hospital and for 30 days after the surgery.

Leaving the Hospital

Discharge
Please plan to be in the hospital for 2-3 days. You will work with the social worker,
physical therapist, and Dr. Kelly’s care team to determine if you will be going home from
the hospital or if a short stay at a transitional care facility is better for you.

Medications prescribed for you at the time of discharge:

1. Aspirin 325mg - You will take a full aspirin (325mg) twice a day for 30 days. If
you were taking a baby aspirin (81mg) prior to surgery you do not have to
resume this until the 30 days of the full aspirin is completed. If you would prefer
to buy this over the counter, please let Lindsey know when she sees you in the
hospital or your nurse.
***If you were taking Coumadin prior to surgery you will resume this instead of
taking the aspirin***
2. Oxycodone 5mg - You will have a prescription for the pain medication that you
were taking in the hospital, this will most likely be oxycodone. Other pain
medications may include Norco, Percocet, or Dilaudid.
  
3. Vistaril 25mg – This medication is a good adjunct to the narcotic pain
4. Senna tabs – This is a stool softener that we recommend you take while taking
narcotics, since the use of narcotics can cause constipation. If you have a
different stool softener that you routinely take at home or would rather buy Senna
tabs over the counter, just let your nurse know.
5. Zofran 4mg – This medication is to treat nausea. Some patients experience
nausea after surgery from the anesthesia or the pain medicine.

Postoperative Information
Pain after surgery
You will be taking narcotic pain medication after surgery to help relieve your pain. Pain
medications are opioid derivative medications that can make you sleepy, dizzy, and
constipated. They are also addictive if used for long periods of time. Please take
narcotic pain medications sparingly but stay ahead of your pain. As you get farther and
farther from surgery you will be able to take less and less pain medication. Patients
typically use pain medication the most to help them sleep at night. Everyone heals
differently but most patients are on pain medication for less than 4 weeks. Make sure to
take the pain medicine that your nurse will offer you the first 24 or so hours after
surgery, even if your pain is low. Chances are, your anesthetic block may still be
working, but when the block wears off, you want to have pain medicine on board and
working to cover that.

Medication Refills
If you need a refill of your pain medication prior to your first post-operative appointment,
please contact your pharmacy and they will contact us. Please allow 24 hours for refills
to be processed. Any refills needed before the weekend will need to be submitted on
Thursday. Also, narcotic pain medication prescriptions
(Norco/Percocet/oxycodone/Dilaudid) cannot be called in to the pharmacy and a hard
copy needs to be signed by Lindsey or Dr. Kelly. This is a Federal Law and there are no
exceptions. You or a family member will need to allow for time to come to our office to
pick this up. As your pain improves we try to help you wean off of the narcotics and
transition to NSAIDs with Tylenol.

Swelling/Bruising
You can expect to have some swelling in your knee for about 6 to 12 months. It is
normal for your knee to be stiff in the morning and swollen in the evening. It is very
important to keep your leg elevated and iced over the course of the first month. Icing
and elevation will help to decrease the stiffness and improve your knee motion. The
best position to elevate your leg is to have the knee above the level of your heart and
your ankle above the knee. You can place a pillow under your calf, not your knee, for
comfort. Ice the knee after physical therapy and 4-5 times a day. Keep the ice on your
knee for 20-30 minutes at a time.
  

Incision
Your dressing and staples will be removed in 10 to 14 days from the date of surgery.
You should leave the dressing alone until your first post-op visit. Lindsey or Dr. Kelly will
check your dressing before you leave the hospital and if it is less than or equal to 50%
blood-soaked, we will leave it intact. Keep in mind that this dressing was placed in the
operating room under sterile conditions and we would like to keep your incision as clean
and protected as possible! Once you leave the hospital, if your dressing starts to come
off or you notice a new blood or fluid collection, please call us and let us know. Once
that dressing has been removed at your post-op visit, you should not put any ointments
or creams on the incision. It is recommended that you refrain from submerging your
knee in water (bath/pool/hot tub) until the incision is fully healed to avoid infection. This
can take 3-4 weeks. However, you may let clean soapy water run over the incision
while showering starting 2-3 days after surgery.

Sleep
Sleep during the first 6 weeks can be difficult due to pain. You should use ice and pain
medication to get as much rest as possible. The Vistaril is good for this, because it is an
anti-histamine and typically makes patients sleepy. These medications will also tend to
make you sleepy throughout the day. Try to get up and move/exercise during the day
and avoid “cat napping” to help you sleep at night. If you are having trouble sleeping at
night the first thing you should try is taking your bedtime dose of pain medication with
Tylenol PM. This has Benadryl in with the Tylenol and can help make you drowsy and
make falling asleep easier. Take this medication as directed on the bottle. If you
continue to have difficulty sleeping at night discuss this with Dr. Kelly or Lindsey. Your
endurance may also be decreased after surgery. The easiest tasks will take longer and
you will tend to fatigue very easily. This will get better as healing progresses and your
strength returns.

Physical Therapy
You will have physical therapy 1-3 times a day while in the hospital. When you are
discharged from the hospital the best exercise you can do to replace the continuous
passive machine (CPM) is ride a stationary bike. This will help increase your knee
flexibility as well as reduce stiffness. You will start by rocking the pedals back and forth
without making a full revolution. You will be able pedal around backwards before you
can go around forwards. You should also work on the therapy exercises given to you
by your Physical Therapist 1-3 times a day.

Physical Therapy will last anywhere from 6 to 12 weeks depending on the individual.
Rehabilitation is very individualized and is tailored to how you feel and progress during
your therapy session. Your therapist will document the progress of your knee flexibility,
pain control, and swelling. You should also keep track of your range of motion to follow
your progression in physical therapy. It is your responsibility to do your exercises daily
and make your therapy appointments. Your commitment to your exercise program is
the key to a full recovery. Most appointments will be scheduled 2-3 times a week at
  
first. The goal is to get 0-120 degrees of motion in your knee following surgery. You
will not get your motion back overnight, but it takes time, patience, and commitment to
your therapy exercises. Leg and knee strengthening will begin at your first therapy
appointment and continue throughout therapy.

You will be using an assistive device such as crutches or a walker to help with your
weight bearing as you heal. Your therapist will help you progress your walking as you
get stronger. Gradually increase how far and how long you walk. You should start with
3-4 short walks every day. After your walk, lie down, elevate and ice your knee to
reduce swelling.

Driving
You will not be able to drive right after surgery. You will need to arrange for a ride home
from the hospital and any appointments or errands in the first couple of weeks after
sugery. You will also want to arrange for rides to your physical therapy appointments at
least for the first few weeks after surgery. You can return to driving when you feel you
can safely operate the vehicle and you are no longer taking narcotic pain medication
during the day.

Life after Total Knee Surgery

Activity
The goal of having your knee replaced is to get you back doing all the activities that you
want to do. This includes walking, golfing, tennis, gardening, and even skiing. One
activity that Dr. Kelly would like you to avoid is long distance running. Since there is a
plastic component to all total knee replacements, distance running increases the risk of
wearing down that plastic and wearing out your knee replacement.

Kneeling
You are able to kneel on a padded surfaced after your total knee surgery. Try to avoid
any prolonged kneeling on a hard surface such as a wood or concrete floor.

Dental Antibiotic
After total joint surgery it is best to wait 3 months before having any dental work or
cleaning done. Once you do go back to the dentist after surgery you will need to take
an antibiotic. You should take this prior to any dental cleaning for 2 years minimum
after surgery, or in some cases, for the rest of your life. The length of time required to
take antibiotics before dental procedures varies based on your overall health. The
antibiotic is to prevent the bacteria from your mouth getting into your blood stream and
causing an infection in your joint. You can call our office before your dental
appointment and we will be happy to fill that.
  
Traveling
You can travel as soon as you feel comfortable after your joint replacement surgery.
We typically recommend waiting one month after surgery before flying due to an
increase risk of blood clots. If you are traveling within the first three months after
surgery you should take one 325mg aspirin daily starting the day before you travel and
continue this one day after you travel. This includes both long road trips or if you are
flying. It is also recommended that you wear compression socks for both long road trips
or while flying.

Please note your joint replacement will make the security alarms go off at the airport.
You simply need to inform the checkpoint worker that you have a replacement and they
will screen you accordingly. You should allow for extra time to get through security at
the airport. TSA is not interested in a security card, however, if you would like to have a
card stating you have a total joint replacement we have them available at the office.

Questions?
If you have any further questions, before or after surgery, please contact us at:
Kaici – Dr. Kelly’s care coordinator: 612-455-2023
Lindsey – Dr. Kelly’s physician assistant: [email protected]

Also, Dr. Kelly’s website has more information on it that can help to answer any
questions or concerns you may have: www.edwardkellymd.com

Below are some of the physical therapy exercises you will be doing after surgery. They
will be easier to perform after surgery if you practice prior to surgery.