Total Knee Replacement Surgery

Loel Z. Payne, M.D.

Diet:

􀀀 You may resume clear liquids and light foods after surgery (jello, soup, etc.)

􀀀 Progress to your normal diet as tolerated as long as you are not nauseated.

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Managing the pain:

There’s no two ways about it, knee replacement surgery is painful. I am going to describe the best ways I have found to try to manage that pain. The first 1-2 days are the hardest. Don’t worry, it will improve.

Before surgery you will be offered a nerve block which helps greatly with pain control and decreases your need to take narcotic medications. I would strongly encourage you to have the block as it does significantly help with pain after the procedure. Additionally, during surgery I will often inject a numbing medicine like novocaine that will give some pain relief for several hours after surgery.

It is important to begin taking your pain medication before this medicine wears off. This is usually about 6 to 8 hours after the procedure. However, it may be as little as 2 hours or (if you’re lucky) it could be 12 to 16 hours. It is important to stay on top of the pain as it is more difficult to catch up.

I do not use a “pain pump” which drips the numbing medicine continually into the joint for several days after the surgery. Several recent studies have shown an increased risk of damage to the joint cartilage and subsequent arthritis as a result of prolonged exposure to this medication.

I believe in using multiple different ways to reduce pain. Our goal is to reduce the amount of narcotics required to control the pain. Narcotic medications (morphine, Percocet (oxycodone), Vicodin (hydrocodone), codeine and Dilaudid) have significant side effects. They can easily become addictive. They can be overdosed, especially in patients already taking other sedating medication such as sleeping pills. Narcotics decrease the body’s trigger to breathe and I may prescribe a medication to reverse this narcotic side effect (Narcan) if you are currently taking anti-anxiety or sleeping medication. It is best to avoid these drugs (and alcohol) while on pain medication. Narcotics cause constipation. They alter your ability to concentrate, cause drowsiness and should not be taken while driving. They can cause hallucinations. They frequently cause constipation and a stool softner, such as Metamucil of Sennokot DS, should be taken daily while on them. They often cause nausea and a medication for nausea, such as Phenergan or Zofran, is often prescribed with them.

Patients with significant reactions to all narcotics, may benefit from a newer drug called Nucynta (tapentadol) that does not typically have the same side effects. However, it may not be covered by many insurance formularies.

If you experience itching, take over the counter Benadryl one half hour before your narcotic.

            Surgery pain stems from multiple factors and you should address each of these to control the pain. Below is a chart to explain our multimodal pain control plan.

 

 

 

 

 

Preoperative pain management

Postoperative pain management

  1. Nerve block – anesthesia injections numbing medication around the nerves that go to the shoulder
  2. Local injection of numbing medication at the surgery site
  3. Anti-nausea medication such as Zofran or Scopolamine patch is given
  4. Tylenol or an anti-inflammatory such as Celebrex may be given
  1. Tylenol 650 mg every 6 hours around the clock. Limit to 3000 mg daily and avoid if history of liver disease. Use continuously for 3 days and then as needed.
  2. Naproxen 500 (2 Aleve) every 12 hours OR ibuprofen 800 (4 Advil) every 8 hours. Take with food and avoid if history of ulcers, severe reflux or kidney disease. Continue for 5 days and then as needed.
  3. Oxycodone 5 mg 1-2 every 4 hours as needed. This is the narcotic and should be used sparingly. However, if pain is severe and uncontrolled with other methods, you may take 3 pills at a time for the first 24 hours. Percocet and Vicodin (Norco) already have Tylenol in them so do not take Tylenol if you are on these medications. Straight Oxycodone does not.

Ice (see below) is very helpful

Physical therapy – stiffness is a common source of pain and therapy is often started several days postop

 

 

  • You will be prescribed a medication to prevent blood clots for three to four weeks after the surgery. Xarelto is a pill that is taken once a day and does not require blood testing to monitor its dose. Since it is a newer drug, some insurance companies do not approve the medication. Another medication for prevention of blood clots is Coumadin. However, this requires monitoring your blood levels twice a week.  Another possible medication is enteric coated Aspirin 325 mg twice a day for four to six weeks. The choice between Aspirin and Xarelto depends on your other medical problems. Some patients with previous stomach problems or on certain medications are unable to tolerate aspirin. If you have a history of clots, I prefer to use Xarelto for prevention. We will talk about which medication to use prior to the surgery. While on a blood thinner you will bleed more easily. Be careful with shaving or activities that may cause you to cut yourself. If you experience bloody noses or blood in the urine or stool, notify our office.

Bandages:

  • Your post-operative dressing is a large Band-aid like bandage. This is waterproof and will allow you to shower while it is on. It does not need to be removed. We will remove it at your first postoperative follow-up visit.

 

Washing & Bathing:

  • You may shower as long as the waterproof bandage is on. However, do not soak the knee in a tub. Do not go swimming until 3 weeks after the surgery.

 

Ice & Activity:

  • One important goal following surgery is to minimize swelling around your surgery site. The best way to achieve this is with the frequent application of ice and elevation of your leg. The ice pack should be large (like a big zip-lock bag or bag of peas) and held firmly on the area of your surgery. You may also have received an ice machine prior to your surgery. This is an ice cooler that circulates cold water around the knee. All ice packs should be placed on top of the bandage. Apply for 20 to 30 minutes three to four times per day if possible. The ice machine also has foot compression wraps that are good for preventing blood clots. You will be instructed on their use prior to the surgery.
  • You may put weight on the operated leg as tolerated. Most people use a walker or cane for about 2 to 4 weeks until the leg feels stronger. You will be in a brace to support the knee and keep it straight while walking. You may discontinue the brace after the first week if the knee supports you well such that you will not fall. You may bend the as much as tolerated. In fact, I encourage you to try to move the knee and walk around after surgery. This helps avoid blood clots and knee stiffness.
  • Do not place pillows under the operated knee as this can lead to stiffness.
  • Place a towel roll under your ankle and tighten your thigh muscles to get your knee to

straighten out. This is very important and should be done at least four times a day for

twenty minutes if tolerated.

  • Move your ankle back and forth many times during the day to help your circulation.
  • You may return to sedentary work in about 3 weeks after surgery if your pain is

tolerable.

  • Do not drive until cleared to do so. Your reaction time to reach the brake will be decreased.
  • Avoid long distance traveling in cars or by airplane during the first month after surgery to

avoid increasing your risk of developing blood clots.

Follow up appointment:

  • We try to give all of our patients a follow-up office visit at the same time we schedule your surgery.
  • Typically, I want to see my patients in the office 2 weeks after surgery. The incision is glued and there may only be several small staples further down the leg.
  • If you have any questions prior to that appointment, feel free to contact me at the office. I would rather hear about a potential problem sooner rather than later.

 

Physical Therapy:

  • You will start physical therapy at home immediately after your discharge. This appointment is usually arranged in the hospital after your surgery.
  • While I prefer patients to go home from the hospital, some patients who do not have enough help or are unsafe to go home, may require temporary admission to a rehab or nursing facility. They will receive therapy at the center until they are safe taking care of themselves at home.

What to watch out for:

  • Pain that is increasing every hour in spite of the pain medication
  • Drainage from the wound more than 5 days after surgery
  • Increasing redness around the surgical site
  • Fever greater than 101.5degrees
  • Unable to keep food or water down for more than one day
  • Call Dr. Payne’s office at 757-827-2480 if there are any problems or concerns.
  • If you experience any emergent problem such as chest tightness, difficulty breathing, unable to swallow, etc, call 911 and go to the hospital emergency room.