When I suggest to a patient that they should consider a knee or hip replacement, they often think that the road to recovery after it will be quite long. However, the modern techniques and technology that are at our disposal as surgeons have significantly shortened the recovery time needed post-surgery. Every surgeon has his or her own strategies when it comes to knee or hip replacement, and my unique game plan allows for rapid recovery from total knee and hip replacements for most patients.
Rapid recovery after knee and hip replacement has three stages.
Stage 1: before surgery
The first stage is educating patients before surgery. All our patients go to a class to learn about knee and hip replacement and recovery.
In addition, we try to find a coach for our patients. A coach could be a spouse, a sibling, a neighbor, or a friend that can help after the surgery when the patient arrives at home.
I want all my patients to get home as quickly as possible after their surgery. Some patients may go home the same day as their surgery. Others might need a day in the hospital. Particularly during the COVID-19 pandemic, reducing time in the hospital is important.
We give each patient preoperative exercises to perform before the surgery to help strengthen the muscles around the knee and hip. These exercises help tremendously in the recovery process.
In addition, we have our patients screened by their primary care physicians to make sure their heart and lungs are in good shape for surgery.
Finally, we have a program to avoid infection where patients wash with a special soap the morning of the surgery.
Stage 2: during surgery
During surgery, there are several steps that we surgeons take to make our patients heal faster.
When we say a knee replacement, what we’re really talking about is resurfacing the end of the bone. It’s about a centimeter of bone that is cut off and replaced with metal and plastic. The way surgeons get into the knee during surgery can vary. For instance, I do not use a tourniquet, a device that stops the flow of blood from a vein or artery. A tourniquet can make a knee replacement go a little quicker since there is less bleeding, but I found that it wasn’t good for my patients. The patients had a lot of bruising and sore muscles afterwards, which slowed their recovery.
I stopped using a tourniquet in 2012 and now use other methods to control bleeding. My patients have been very happy since that transition.
Pain control starts during surgery. We have our anesthesia team inject the knee with a block be-fore surgery. The block helps keep the knee pain-free or close to pain-free for up to 24 hours after surgery. During the surgery, I inject a numbing medicine and an anti-inflammatory medicine that last for up to 12 hours all around the back and side of the knee.
For knee replacements, I use a robot called the Mako. The Mako allows me to make more precise cuts, and I don’t have to cut as much soft tissue in order to get into the knee.
For hip replacements, we use some techniques that are unique to the hip. In a hip replacement, we replace two sides of the ball and socket joint. We put a titanium and plastic implant in the pelvis, which becomes the new socket. On the femur (leg) side of the hip, we have a titanium implant that wedges into the femur with a special coating called hydroxyapatite. These two pieces go together to make the hip replacement.
I use an anterior approach where the incision is on the front of the hip. I don’t cut any muscles, creating less pain afterwards. Additionally, I have a special carbon fiber table called the Hana table that allows me and my team to position the leg in the best positions to perform the hip re-placement, allowing for quicker recovery and less pain post-surgery. I also use the same injections to reduce pain and inflammation around the hip that I use for knee replacements.
We have a computerized system that allows me to measure the leg length of my patients during hip replacement. Most people don’t realize we change the length of the leg when we replace a hip. Obviously, we don’t want our patients to have one leg longer than the other, so we use a computer navigation system to equalize leg lengths.
Stage 3: after surgery
After surgery, there are many different forms of pain control that we do. The first one is ice. There are several styles of ice packs. Your typical bag of frozen peas works wonderfully, but it gets warm after about 10 minutes. We have a special ice wrap for patients with a hose connected to a cooler. The cooler continuously circulates cold water to the ice pack, so you don’t have to constantly refresh the ice.
We also like to use non-narcotic pain medications. Tylenol around the clock in higher doses is very effective at relieving post-surgical pain. In addition, we use anti-inflammatory medications to help with muscular pain.
We do use some narcotics after the surgery but in a very limited fashion. My goal is to get all my patients off the narcotic medication within two weeks post-surgery.
After your knee or hip replacement you will have a physical therapy consult in the hospital. The therapist will remind you of the exercises you learned before surgery. You will do these exercises at home on your own time. They should be done every hour while you’re awake. The exercises are very simple and are posted on my profile on our OrthoVirginia website. By having our patients do exercises on their own at home for the first two weeks, we avoid causing more pain during sessions with the physical therapist.
Our physical therapists are terrific and want the best for our patients. After doing exercises on your own for two weeks, you’ll come back to my office, I’ll examine you to make sure you’re do-ing well, and then I’ll connect you with our physical therapists.
Frequently asked questions
Do all surgeons use this program?
No, everybody has their own recipe so to speak. Recovery programs will have the same ideas, like pain control and physical therapy, but the exact details vary between surgeons.
Why would swelling occur all the way down to the ankle after a knee or hip replacement?
When you have a knee or hip replacement gravity comes into play. For example, if I’m sitting in a chair, my knee and hip are below my heart, and my foot is even lower. Blood flows downhill. After the surgery, we don’t have a pump to get the blood back uphill, so we have to use gravity. Elevating the leg is crucial to get the blood back to the heart and to return the body’s blood flow system to normal.
Even if a person elevates their leg exactly as they're told they will have some swelling all the way down the leg and ankle. This situation is where the patient education comes in to play. If the patient knows about the swelling ahead of time, it’s no big deal. If we did not adequately in-form the patient about the swelling beforehand, then they may be surprised, and that can be a little stressful.
What percentage of total knee replacements are successful?
The literature shows about 85% to 95% of knee replacements are successful. Those are great numbers, but that also means anywhere from 5% to 15% of people are not happy with their re-placement. So, knee replacements are not perfect. In the early recovery phase, I think it’s too early to confidently say if the replacement is going to be successful or not.
What is the clicking noise I hear in my joint after knee replacement?
When you have a knee or hip replacement, the cartilage and bone are replaced with metal and plastic. Cartilage and bone can click and creak but not in the same way a knee replacement creaks. The sound you hear after a knee replacement is metal and plastic.
In my experience, noises in your knee don’t happen immediately after the surgery because there’s a lot of fluid in the knee. As the fluid comes out of the knee, you usually hear the clicking or creaking a little more. As the muscles around the knee replacement get stronger, there’s a lot less clicking.
What is the life expectancy of a total knee replacement?
The life expectancy is 15 to 20 years. The implants we are using today are a lot better than the older ones. There are certain things that will cause the knee to wear out earlier. The first one is patient weight. The lighter you are, the longer the replacement will last.
The second factor is activity level. I don’t want patients to wear out their knee replacement, but I also want them to enjoy the knee. So, I wouldn’t worry about limiting activity.
The last factor is that women’s knees tend to last longer than men’s. There’s not much we can from that standpoint besides controlling weight.