Figure 1.Be as active as possible before surgery.
Pre-op Preparation
Recovery after surgery is optimized when you prepare well.
- Be active (e.g., walking, stationary bike, light work). (Figure 1.)
- Eat healthy foods.
- Avoid exposure to cold and flu viruses.
- Shower or bathe thoroughly each day for 3 days prior to surgery.
- If you notice any open wounds, scabs (figure 2), or infections such as an ingrown toenail (figure 3), contact us immediately. It may be necessary to postpone your surgery to maximize safety and minimize infection risk.
- Follow the instructions outlined in your Pre-surgery packet you received from RCM clinic prior to surgery.
- Plan for follow-up visits at about 2 weeks, 6 weeks, 5 months, and 12 months. If you live out of town, a 5-6 month visit is recommended. The others are optional.
- Arrange for a driver to take you to your appointments and physical therapy (PT) sessions for the first 3 to 4 weeks after surgery.
- You will leave the hospital with a continuous passive motion (CPM) machine that you will use at home. You will need a firm mattress to support the CPM machine (see figure 5 video below).
- You will be using forearm crutches (or a walker) during the first 2 to 4 weeks after surgery. Please create a long, unobstructed walking track inside your home (see figure 8 video below).
Intermountain Pre-op Joint Replacement Class
An Intermountain Pre-op Joint Replacement class (at PKMC) is typically held the 1st and 4th Monday of each month. You will receive a call from the pre-admission nurse approximately 2-4 weeks before your surgery to invite you and to give you details on time and location. This class outlines what you will need to bring, what to expect on the day of surgery, hospital amenities, physical therapy, and discharge planning.
Figure 2.Scab.
Figure 3.Ingrown toenail.
In-hospital Rehab
You are in the hospital 2-3 nights after surgery, and will have goals to accomplish on each day. Physical therapy begins the same day as surgery. Here's what you can expect:
Day of Surgery
- You are given a breathing exerciser (incentive spirometer) to maintain lung function. Use your spirometer for 10 breaths every hour while awake.
- Walk 25-50 feet with your physical therapist while using your walker for support.
- Your lower limb is placed in a Continuous Passive Motion (CPM) machine that will bend and straighten your knee up to 90 degrees initially (see figure 5).
- The CPM machine is used 6-8 hours per day. The physical therapist and nursing staff will assist in proper positioning (see figure 6).
- To prevent blood clots, pump your foot up and down, preferably against resistance, at least 10 times every hour you are awake.
Your physical therapist instructs you in the following exercises: ankle pumps, assisted straight leg raises, heel slides, passive knee flexion stretching, and short arc quads.
Figure 6.Correct position of limb in CPM machine.
Day 1 Post-op
Twice daily physical therapy sessions begin.
- Sit in a chair or on edge of bed for lunch and dinner.
- Walk 100 feet in the hallway with support of a walker and to and from the bathroom when needed.
- Increase CPM machine to 100 degrees.
- Perform straight leg raises, quad sets, short arc quads, and chairslides (see figure 7 below) as introduced by your therapist
- Continue 10-20 resisted ankle pumps every hour while awake
- Transition off IV pain meds to oral meds exclusively in preparation for discharge home the next day
- Learn to navigate stairs with forearm crutches (figure 8)
Discharge Day Goals
- Pain managed on oral meds exclusively
- Ambulate with assistance to the bathroom independently
- Demonstrate safety on stairs and transferring in/out of bed.
- Walk at least 200 feet continuously with your therapist
- Review home exercise program with your physical therapist
- Continue POD #1 activities (quad sets, short arc quads, straight leg raises, chair slides)
- Advance range of motion on CPM beyond 100 degrees flexion
- Dressing changed to waterproof wound cover (figure 9)
Figure 9.Waterproof wound covering.
In-home Rehab (approx day 4 thru 2 weeks post-op)
Rehabilitation Program
- Hands-on joint mobilization, AP glides, patellar mobs (figure 10), swelling reducing massage techniques, and review of gait training with crutches should be implemented by your home therapist.
- A home therapist will assist you typically three days per week. Each session should last at least an hour.
- Perform the following exercises 4 to 5 times every day: quad sets, straight leg raises, and mini-squats.
- Continue CPM at home until 21 days post-op, maximize the range of motion on the machine and continue use 6-8 hours per day. Some patients enjoy sleeping in the machine.
- Walk with the forearm crutches three or more times daily, increasing your distance gradually.
- Range of motion exercises are recommended 6+ times per day. Exercises emphasizing flexion include chair slides and heel slides. Exercises emphasizing extension include supine extension stretch, hamstring stretch, and calf stretch
- Your range of motion comes gradually with greatest success from frequent repetitions.
Figure 10.Patellar Mobilizations.
Important Information
- Outpatient physical therapy three times a week is recommended 7 to 14 days after surgery.
- You may shower with waterproof dressing in place. Avoid bathing for 3-4 weeks or until wound is completely healed.
- Return for a follow-up examination approximately 2 weeks following surgery at which time skin staples will be removed. If you are from out of town, we may arrange for staple removal near your home.
- Standard post-op medications during this time period include stool softeners, blood thinners, and pain relievers such as Lortab or Percocet. You may resume NSAIDs (non-steroidal anti-inflammatory drugs) if necessary after xrays are obtained at approximately 6 weeks post op.
- Avoid sitting for periods greater than 30 minutes.
- To reduce swelling, elevate your knee above heart level typically 2-4 hours during the day and while you sleep. (Figure 11)
Figure 11.Ideal knee elevation technique.
Outpatient Rehab (2 to 6 weeks post-op)
Important Information
- We work with physical therapists in various locations familiar with athletic knee implant rehab. Following your 2 week post op appointment, we can make a referral to one of these therapists.
- We encourage open communication with our therapists and expect them to notify us if you fail to make progress in your rehab program.
- Your range of motion goal for this time period should be a minimum of 0-110.
- Wean narcotic pain medication gradually by increasing the time interval between doses. Try to control post-op pain exclusively with over-the-counter medication by 6 weeks post-op. We recommend extra-strength Tylenol every six hours if needed.
- You may discontinue use of the T.E.D. stockings after six weeks.
- You may resume driving when you no longer require crutches (and unaffected by narcotic pain medication).
- The approach to your therapy program should entail hands-on soft tissue mobilization and gradual ramping of exercises. Aggressive manipulation is not recommended (no brute force). Gentle stretching should emphasize repetition and frequency.
- Early emphasis on range of motion and flexibility exercises should be your focus.
- Activities highly recommended for flexion: chair slides 6-8 times daily, low-seated stationary cycling twice daily (once approved by your therapist).
- Activities highly recommended for extension: pilates ring stretch 6-8 times daily (figure 12), long-striding gait, supine extension stretch, and walking backwards on a treadmill.
- A walking program should be prioritized and aquatic therapy if pool is available.
Figure 12.Pilates ring stretch by a triathlete with bilateral knee replacements.
Self-directed Exercise Progam (6 to 12 weeks post-op)
IMPORTANT INFORMATION
- Move entirely to a self-directed exercise program.
- Work to achieve 0-130 degrees range of motion
Rehab
- Gradually increase walking to 1-2 miles per day.
- Gradually increase stationary cycling to 15-30 minutes per day.
- The following strengthening exercises may be introduced by your therapist:
- mini squats
- toe raises
- hamstring curls
- leg press
- hip isotonics
- Continue the flexion and extension exercises outlined above until you have achieved 0-120 degrees of motion.
- Again, repetition and frequency work best over brute force!
Self-directed Exercise Progam (3 to 6 months post-op)
- Stretch daily to improve flexibility in your spine, hips and ankles.
- Do your best to walk smoothly without a visible limp.
- Begin adding activities like hiking gentle hills, performing light yard work (lifting up to 20-30 lbs.), and outdoor cycling (only if safe).
- Return to golf safely by working on your short game around 3 months post-op, playing 9 holes at 5 months post-op, and 18 holes at 6 months post-op.
- Plan on being cleared for 18 hole golf, skiing, racquetball, backpacking, river running, and similar activities at your 5-6 month post-op appointment. Please wait to participate in these activities until you have received clearance.
General Information
Develop Long-term Rehab Habits
- Participate in daily cardio exercise such as elliptical trainer, hiking, or cycling.
- Gradually achieve and maintain a healthy BMI (body mass index).
- Eat a well-balanced diet and follow our plant-based diet guidelines.
- Wear shock-absorbing shoes.
- Consider pharmaceutical grade nutritional supplements like bi-daily Nutriex or equivalent.
- Unless approved, avoid most high impact activities like basketball, long distance running, and hiking (with backpack greater than 30 lbs) in order to maximize implant longevity.
- Minimize prescription drugs and be aware of drug side effects.
