325 East Sonterra Blvd.
Clinic: Suite 120
Administrative Office: Suite 220
San Antonio, TX 78258
Phone: (210) 614-5100 / Fax (210) 614-5103
Adam I. Harris, M.D.
San Antonio Orthopaedic Specialists
Adam I. Harris, M.D.
You have elected to receive a total knee replacement or uni-compartmental knee replacement by Dr. Harris using minimally-invasive, tissue sparing techniques. The techniques employed are all tissue sparing though the details may vary slightly from one patient to the next. These techniques do not cut into the muscles or tendons as do the standard techniques that have been employed by most surgeons since the 1970's.
This pamphlet is designed to provide information about the surgery and postoperative care and nutririon, and to answer the most common questions that most patients have. Please share this with your family and your therapists. If everyone is "on the same page," then your course through the surgery and rehabilitation should be smooth.
Your Hospital Stay
You will be admitted to the hospital on the day of your surgery. The hospital stay is usually two to three days thereafter. Most people are able to go directly home after the hospital stay. The length of your stay depends on many things. The better your general condition before the surgery, the shorter your hospital stay is likely to be. Those with single-level houses and supportive and available families also will have shorter stays. Those living by themselves or with "obstacles" at home (such as a large number of stairs) tend to stay longer.
The exact length of the stay is, in a sense, a "game" where many of the rules are made by the government and the insurance companies. The only portion that is true to “medicine” is that you should stay in the hospital until you are medically stable. Further, you should not go home until you are safe to go home to your home environment. Now, the “game” in the system. In general, if “medically stable” and “physically safe” are separated by about a day, then you can stay an extra day in the hospital, then go home. If they are expected to be separated by several days, then you will be transferred to a rehabilitation facility. Experience with these procedures is that for those under eighty years of age, a rehab stay has been needed about two per cent of the time. About forty percent of those over eighty do require a rehabilitation stay.
The hospital stay is not a recipe where the patient is merely an ingredient. People respond to the surgery differently. Most get up quickly, but some go a little more slowly. It is NOT possible to predict who will “bounce” and who will need some more time. The length of the stay cannot be absolutely predicted before the surgery. The length of the stay is determined after the surgery. Dr. Harris will do what best fits each individual patient.
What can I do before surgery to minimize my risk of infection?
First, the record of known infectious complications in this office is better than published reports. Unfortunately, the so-called “super bugs” have become very common in the community in some studies representing 30% or more of organisms cultured off otherwise healthy skin. Therefore, a shower or bath with a Chlorhexidine based soap (Hibiclens and others) may reduce your risk. Please be careful though! Some people are allergic to this soap. Dr. Harris recommends washing for several days before the surgery in the region of the incision with Chlorhexidine. Please try the soap on the opposite side a week or more before to be sure that you tolerate the soap. Rashes or blisters near the incision area will force postponement of the surgery. Chlorhexidine soaps are available at most drug stores, and many groceries without prescription.
Next, while losing weight is a good thing for most of us, if you’re overweight, don’t scrimp on protein in the few weeks before the surgery. Adequate protein levels are important with regard to wound healing. Short term increases in cholesterol or fat intake will not be significant in the long run. If you have concerns about “eating meat” please bring them up to your primary care physician. It is outside the realm of this office to make more specific nutritional recommendations.
Tell Dr.Harris about any remote (away from the surgical area) infections. Boils, open wounds, and decaying teeth are a few examples. Check with your primary care physician about urinary tract and sinus or respiratory infections. Check with your dentist to be sure that you have no active infections in your mouth.
Lastly, avoid cuts and scratches in the region of the planned incision. A common reason that women have their knee surgery postponed is that they shave and nick the skin near the knee. Men tend to try to get one last garden project done before the surgery and end up with ant bites or deep cuts/scratches. If you shave in the area of the surgery on a regular basis, please don’t do so for five to seven days before the surgery.
Like the stay itself, the plans for care after the hospital stay vary from patient to patient. In most cases, the ideal situation is for the patient to go home and from there go to outpatient physical therapy. It is simply not practical to do this for each and every patient. That which may work for one patient won’t work for the next. A key determinant here is the function that is gained during the hospital stay. Discharge plans are made as you progress with the therapy in the hospital after the surgery. Dr. Harris will do what best fits each individual patient.
Physical therapy starts the day of or the day after the surgery. The goals of the therapy are three fold. The first goal is to make you independent. The second is to help you gain the maximum range of motion of your new knee. Last of the goals is regaining strength and stamina. As there are a great many therapists, signals can occasionally get crossed. Please share this information with your therapist. Unless you hear from Dr. Harris personally that he has changed the plan for your knee, this pamphlet describes your therapy protocol.
In general, Dr. Harris prefers that patients attend outpatient physical therapy as opposed to inpatient rehabilitation or home health. While this program does not fit every patient well, there are good reasons for this preference. Good studies have shown that patients experience less pain at home than they do when they are in any inpatient facility. Further, while at an inpatient facility, if you want a drink of water, you hit a button at the bedside, and someone brings it to you. At home, you’re likely to get up and walk to the kitchen yourself. This is also part of your therapy. As far as home health is concerned, the better therapists, in general, work for outpatient centers. (Exceptions do exist in both directions.) Unfortunately, many home health therapists charge for the transit time, and patients get 10-15 minutes of therapy instead of an hour or more.
Range of Motion
The work on range of motion is aimed at maintaining both extremes of motion. On one end is a completely straight knee (extension); on the other is a maximally bent knee (flexion). Both of these goals are obtained in the operating room. After the anesthetic wears off, motion may be painful. It is less painful with the tissue sparing technique, but rarely is it pain free. How painful will vary with many things, but you will be given plentiful pain medication. However, the more that you move your knee early in “the game”, the less it will hurt to move your knee later.
The character of the pain should be different. Most people can tell the difference between post-surgical pain and the arthritic pain before the surgery. The relief of the arthritic pain has led some people to be very happy with the initial pain relief but avoid the post-surgical pain by not moving the knee. In the first few weeks after the surgery, gaining motion is much more important than cutting down on pain medication. In short – take the medicine and do the exercises.
Many patients can achieve 120 degrees of motion in the first two weeks. Even if they require six to eight pain pills per day to do so. In the long run, the patient who accomplishes this will fare much better than the patient who has tapered to one pill per day and only bends 80 degrees.
Gaining range of motion is divided into two parts. When you’re in bed, do not prop your knee with pillows. Use this time to work on extension. Perhaps place the pillows under your heel, and allow gravity to help straighten your knee. When in a chair, do not prop up the surgical leg on a pillow or ottoman. Instead, place the heel of your opposite leg in front of the ankle of your surgical leg and use it to push the knee into greater flexion. The tendency is to do exactly the opposite, supporting the knee in mid-flexion with the ankle of the opposite foot. Again, please take the medicine and do the exercises.
Many patients ask about continue passive motion machines Most surgeons in this area use them. There may be some very short-term benefit to these machines. The long-term benefit of continuous passive motion is by no means proven. The machines hurt, and patients on these machines need more pain medicine than those who don’t use them. Those who advocate their use claim that the need for forceful manipulation is decreased. Dr. Harris’ patients very rarely need manipulation—even without the use of the motion machine.
Weight bearing and Assistive Devices
Unless Dr. Harris has specifically told you otherwise, you may bear weight on your surgical leg as you tolerate it. Use a walker, crutches, or a cane as you need to, to keep yourself from falling over. Use these devices only as long as you need them, not one day longer. On the flip side, no patient has Dr. Harris's permission to fall and break anything. He does not give out airline miles for your returning to the hospital with something broken.
The first question is really, “When should the operative dressing be removed?” The answer to this question depends on the type of dressing, and the type of the incision. Standard surgical dressings can be identified by the clear plastic overlying gauze. These surgical dressings should be removed two to three days after the surgery. Then, a clean, dry dressing should be placed once a day, or more often as needed. Only the surgical dressing is held on with plastic. Subsequent dressing should allow the wound to “breathe”. It is not unusual for there to be a few drops and up to a silver dollar-sized spot on dressings of blood or clear yellow fluid from the incision. You should clean the wound with sterile normal saline or dilute hydrogen peroxide (one part hydrogen peroxide to three or four parts water or saline). Please do not use full strength hydrogen peroxide or alcohol to clean the wound. Full strength peroxide will do more harm than good, particularly if used repeatedly. A thin film of antibiotic ointment is not harmful, but also not needed. If there is drainage and it is green or cloudy, increasing in volume, or more than a silver dollar's worth a day, or the wound appears an angry red, then call the office immediately.
Many patients will receive a “long term” dressing. These can be identified by the thicker brownish color of the dressing, and that gauze cannot be clearly/easily seen through the dressing. These should stay on for seven to fourteen days after the surgery. Basically, when they start to come loose at the edges, help them off. If they lift up enough that there is a path from the central dressing to the edge, then remove the dressing and start wound care as above. Attempting to remove this dressing early is hard on the skin along the edges.
The initial surgical dressing is waterproof. You may shower with this dressing in place. (No soaking as in a bath tub or pool). If the dressing fails, and the wound gets wet, remove the dressing, and start local care as above.
After the wound has been clean and dry for 48 hours, then you may shower without protection. The running water is good for the wound. Soaking is not good for a fresh operative wound, so don’t sit in tubs, pools, or lakes, etc. A lightweight dry dressing may help keep clothing from rubbing on the wound.
Before the wound is "bone dry," you may also shower with some preparation. To do this, get OpSite, Tegaderm or any other waterproof over the counter dressing, and cover the wound. These are waterproof dressings that are available over the counter. They look a little like Saran Wrap™ with one sticky side. After the shower, remove the waterproof dressing and replace the regular gauze. Stay out of tubs and pools until the wound is at least three weeks old.
Without some protection, after joint replacement, there is a risk that you’ll develop an abnormal blood clot in your leg. These clots can break off and cause all sorts of trouble, particularly in the lungs. Many web sites, sponsored by the makers of the blood thinners advertise that without (their drug as) prophylaxis for these clots, 1% of elective patients died from this complication. There is however, NO good evidence for this claim. With any form of prophylaxis, the rate is around 0.02%. Therefore, after your joint replacement, you will receive treatment to prevent abnormal blood clots. Since 2007, Dr. Harris has followed the recommendation of the American Academy of Orthopædic Surgeons. This has proved to be both safe and effective.
Many physicians and other health related professionals though still believe that the recommendations of the American College of Chest Physician’s 8th edition of guidelines (and earlier versions) are the gold standard. The Center for Medicare and Medicaid Services has recently adopted the ACCP 8th edition guidelines. By contrast, Dr. Harris has proof that the 8th edition guidelines are dishonest. The ACCP 9th edition guidelines, published February 2012, are very much in line with the AAOS guidelines. So, if another physician, therapist, nurse, or insurance agent tells you that you need something stronger to make your blood thinner, please tell them to catch up. You will receive state of the art treatment for this potential issue.
Most patients will receive a combination of aspirin, early mobilization, and sequential compression devices. A few patients will be better served by alternate drugs. The duration of therapy may range from 10 days to 6 weeks. You should refrain from using other types of blood thinning drugs while you’re on the prophylactic medicine. For example, anti-inflammatory medications, like aspirin, are platelet inhibitors. If you are using aspirin for prophylaxis, you may use non steroidal anti-inflammatory medications (NSAIDs), but not Vitamin E, Glucosamine, Garlic, etc. If you’re on a heparin like drug, you should not use NSAIDs, or Coumadin. This can be confusing. If you have any questions, please ask before adding a drug that could make your blood too thin.
Dental Work and other procedures after Knee Replacement
Many things that we do during ordinary activities will cause some bacteria to float around in our blood system. Simple acts, like brushing your teeth or moving your bowels will cause a detectable rise in the number of bacteria in the blood. For these ordinary activities, some very very sensitive tests are needed to detect the levels. For some activities, such as dental hygiene at the dentist’s office are thought to spill a larger number of bacteria into the bloodstream.These bugs can take up residence on the metal of your prosthesis, and cause all sorts of problems.
For decades, orthopaedic surgeons have recommended that you a single dose of antibiotics 30 to 60 minutes before such procedures. In early 2013, the American Academy of Orthopaedic Surgeons changed the recommendation. It is now very “Charlie Brown-ish”. Recent reviews of the literature suggest that there really is not adequate evidence for this traditional recommendation. The conclusion of the review is that the doctor may not want to routinely recommend prophylactic antibiotics. I take two things from this review. First, it is probably more important to maintain good dental hygiene day to day than to worry about the dose before seeing the dentist. Secondly, when one of the authors of the AAOS review was asked what he did for his patients, he responded that he gives them antibiotics. Therefore, until there is “more evidence”, I recommend using antibiotics before dental hygeine every time, indefinitely.
If you choose to take the antibiotic, then you can get the prescription from your dentist, your primary care doctor, or from me.
Larger procedures, such as “standard” surgery should be accompanied by preoperative antibiotics anyway, and no special additional medications are needed to protect your prosthesis. In the past, prophylaxis for other procedures that stir up bugs such as colonoscopy was recommended. This is no longer the case.
Other Frequently Asked Questions and Occasional Problems
1) When should the stitches be removed?
The stitches are usually removed about two weeks from the time of the surgery. You should call the office if you don't already have an appointment in this time frame.
2) When can I drive?
There is not a scientific answer to this question. There are many people driving right now that have no business being on the road who did not have recent surgery. What little data is available is primitive, and looks only at reaction times. There is a great deal more to driving than just reaction times. Dr. Harris is admittedly conservative on this issue. The real question is not whether you can operate the vehicle. That you’d be able to do in a few hours after the surgery. The real question is, “When can you respond appropriately to an emergency?” If you are going to think twice about your hip or your knee before responding to the emergency that is in front of you, don’t get behind the wheel in the first place. When Dr. Harris’ kids were younger, he’d tell the patients that if they were going to drive early, call him at home so that he could keep them inside.
The limited data that does exist tells us that reaction times are not as good as before the surgery for six weeks. Therefore, if you want Dr. Harris’ “blessing” to drive, then you will have to wait six weeks. If on the other hand, you feel that you can respond the the emergent issue in an appropriate manner, then you are (or at least should be) a responsible adult. It becomes your decision.
3) How much pain medication should I take?
You should have a prescription for a narcotic-containing pain medicine. Use this medication as you need it. In general, no more than nine tablets of narcotic pain medicine per day. By three weeks, you might be using four to six pills per day. By six weeks, about three to four pills per day. Please re-read the section on range of motion. It is far better to take a little more medicine and get better motion. It is legitimate to use pain medicine before physical therapy or home exercise sessions. Otherwise, don't take pain medicine "in case you might have pain."
The common prescriptions after surgery all also contain Tylenol. (APAP is an abbreviation for acetaminophen, which in turn is generic for Tylenol.) Please be careful about the "non-aspirin pain relievers" during the first six weeks. Most of these contain anti-inflammatory medications. These are also blood thinners and can interact with some of the blood thinners that you might receive. Others contain plain Tylenol. Stay within the over-the-counter limits for total Tylenol per day.
If there is sudden onset of dramatically increased pain, call Dr. Harris immediately. Truly emergent problems that require a late night trip to the emergency room are rare.
4) What about anti-inflammatory drugs (NSAIDs)?
Dr. Harris prescribes an anti inflammatory drug on the day of the surgery and for six weeks after that. Thereafter, the use of NSAIDs will depend upon the type of blood thinner that is used. NSAIDs themselves are blood thinners. They belong to the category of thinners known as platelet inhibitors. If you are on aspirin after surgery, it is also a platelet inhibitor. You may mix platelet inhibitors, and use NSAIDs in addition to aspirin.
However, if you’re on a different blood thinner, you shouldn’t mix two different types of blood thinners. In that setting, NSAIDs should be avoided.
5) How long do I take Blood Thinners?
There is no more consensus as how long blood thinners should be used after knee surgery than there is which method is best. If the hospital where you have your surgery can provide the ambulatory sequential compression devices, then treatment will last ten days to two weeks. If not, then Coumadin will be used for ten days, followed by low dose aspirin till six weeks from the time of the surgery.
If you are on Coumadin, then one doctor should manage your Coumadin. Problems arise more commonly if the responsibility for anticoagulation management shifts back and forth. Dr. Harris will initiate the therapy, and prefers to manage it for the entire time that you are on Coumadin. When a primary care physician insists, then the doctor managing your Coumadin may change once during your treatment. If another doctor is current managing yours, then ask that physician. Dr. Harris specifically recommends levels of anticoagulation consistent with the AAOS guidelines, or the ACCP 9th edition guidelines. The ACCP 8th edition guidelines are dishonest and in the opinion of many orthopædic surgeons, dangerous for this setting. If on Coumadin, you will require periodic blood tests to measure the effect of the drug on your system. Dr. Harris tries to limit the number of times that he sends the "vampires" to your bedside. But as your activity increases and your diet changes, your requirement for Coumadin changes.
6) When do I start physical therapy?
The day of surgery! If you're awake enough and the therapist has not been by, please bug the nurse to call the therapist. During the first week or two, you should have therapy every day or more often. Thereafter, the demand for therapy varies greatly from one patient to the next. In rare circumstances, insurance will place severe limits on physical therapy. In these cases, Dr. Harris may “hold on to physical therapy days” and restart therapy at a later date. Otherwise, your therapy should not be interrupted. Complain to your insurance company or as appropriate to your primary care physician to be sure that your therapy continues. Alternately, if you feel that you’ve accomplished all of the goals of physical therapy, discuss stopping early with Dr. Harris.
7) What about sex?
This is generally not an issue for knee replacement patients. It is mostly a question of comfort. If you choose a position on your knees and it is in the first month after surgery, be sure that the knee is well padded. (Good, soft, and clean knee pads also apply to any kneeling.)
8) What should I do about drainage?
A small amount of drainage is not unusual. In general, more than a drop or two of drainage should not persist beyond a week from the time of the surgery. Normal drainage is clear, clear-yellow, slightly pink, or clear and blood stained. If the drainage is cloudy, green, or malodorous, call the office. Drainage that has been sitting on the dressing for a while may change colors on the dressing or become malodorous. The concern is the color of the active drainage, if any.
9) The knee is red, hot, or hard. What should I do?
Three different issues are common in the knee replacement patient. First, a pink color or a bruised color is very common. These are not a concern. Fire engine red is a concern. If you believe that your knee is fire engine red, please come in to the office promptly, or at very least call.
The second is that of temperature. If you feel closely enough, a replaced knee will be slightly warmer than the opposite knee for up to a year and a half. Warm is OK. The knee will be warmer after exercise and cooler after rest. Truly hot is a potential problem. Again, call, and come in.
Lastly, a few percentage of patients will have, as part of their knee replacement, a "lateral retinacular release." This portion of the procedure loosens some of the tissue on the lateral or side of the knee away from the other leg, so that the kneecap can ride down the center, where it belongs. If your knee is swollen or hot or red only on the outside of the patella and not over the wound, it is rarely a problem.
Again, it is common for the wounds to be a little pink after any surgery. If the wound is red, hard, painful, or tender, then you need to be evaluated in the office. Call now! Bottom line is that it is much better for you to be seen in the office when it was not otherwise necessary than to miss an opportunity to treat a problem while it is still small.
10) I have a fever of 100°. What should I do?
A low-grade temperature is common after any open orthopedic surgical procedure. This is a result of some blood getting in between the muscles and the body trying to absorb the blood. Temperatures in the 99 to low 100's are not considered fevers. Temperatures over 101° may represent a problem, particularly if you feel "ill" at the same time. A measured oral temperature over 102° should prompt an immediate call to the office.
11) When should I call the office?
If there is something that you don't understand, or if you have a concern not covered in these pages, please call. Dr. Harris is a firm believer that there are exactly two types of "stupid questions." There are those that you don't ask, and there are those that you ask five times. Everything else is legitimate. These frequently asked questions are updated periodically. If there is a topic that you think should be covered and is not, please let us know.
Adam I. Harris, M.D.
Frequently Asked Questions:
Total Knee Replacement
Other Frequently asked Questions