Background Information:

What are the other Names for the Procedure?

• TKR (Total Knee Replacement)
• Total Knee Arthroplasty

What is Total Knee Replacement surgical procedure?

• Total Knee Replacement (TKR) is a surgical intervention that involves the complete removal of the knee joint and placement of an artificial joint or prosthesis. The prosthesis has metal and plastic/ceramic components
• This procedure, which is also known as Total Knee Arthroplasty, is recommended for individuals with long-standing joint disorder that interferes with proper knee function

What part of the Body does the Procedure involve?

Total Knee Replacement involves the knee joint, muscles, surrounding ligaments, bones, and bursa, which shape the knee joint.

Why is the Total Knee Replacement surgical procedure Performed?

A Total Knee Replacement surgery is performed for the following reasons:

• Degeneration or deformity of the knee joint
• Injury to the knee, which causes pain and reduces mobility, impairing an individual’s quality of life

What are some Alternative Choices for the Procedure?

A few alternatives to Total Knee Replacement procedure include:

• Use of analgesics, braces to support the knee, and modifications to one’s lifestyle, are choices used to manage knee joint disorders. However, when none of these modalities are able to control the symptoms or improve one’s quality of life, a surgery may be the only option left
• Arthroscopy is a procedure in which an instrument, called an arthroscope, is introduced into the knee through a small incision, to examine the joint directly. It may also be used sometimes to treat a joint damage and can be used to remove damaged tissue. This procedure is usually adopted for milder osteoarthritis and can only delay a TKR procedure, but not completely avoid it

What are the Recent Advances in the Procedure?

Total Knee Replacement surgery is a gold standard procedure. Recent advances in the procedure relate to the materials used, to replace the knee joint.

What is the Cost of performing the Total Knee Replacement surgical procedure?

The cost of Total Knee Replacement surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Total Knee Replacement surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.surgery.com/procedure/knee-replacement/ (accessed on 08/02/2014)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267526/ (accessed on 08/02/2014)

Blood loss in total knee arthroplasty: An analysis of risk factors; Narayana Prasad, Vinod Padmanabhan, and Arun Mullaji

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

Prior to Total Knee Replacement surgical procedure:

How is the Total Knee Replacement surgical procedure Performed?

The Knee Replacement procedure may be carried out on a single knee, or on both the knees (Bilateral Total Knee Replacement). The procedure is performed under general, spinal, or epidural anesthesia, and involves the following steps:

• The orthopedic surgeon incises the skin over the damaged knee
• Avoiding damage to the ligaments supporting the knee, the surgeon enters the joint capsule (the structure surrounding the knee joint) and cuts out portions of the bones forming the knee joint (the femur above and the tibia below)
• The artificial parts, called ‘prostheses’ are then attached to the femur and the tibia in sequence. The metal components fit over the bones
• Plastic parts called “spacers” are placed between the metal prostheses and also between the kneecap and the prostheses. The spacer prevents friction between the moving parts
• The orthopedic surgeon then ensures proper movement of the joint and checks to see, if the ligaments and tendons are intact, before closing the incision

Where is the Procedure Performed?

A Total Knee Replacement surgery is generally performed at a hospital.

Who Performs the Procedure?

An orthopedic surgeon performs a Total Knee Replacement procedure.

How long will the Procedure take?

The replacement of a single knee joint may take about 2-4 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Total Knee Replacement surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Normally local anesthesia is not used; however do inform the physician if you are allergic to any local anesthetics, lidocaine, etc
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Total Knee Replacement procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Total Knee Replacement surgical procedure?

Before a Total Knee Replacement procedure, the patient has to undergo certain tests, such as:

• Routine blood and urine analysis
• EKG
• Chest X-ray
• X-ray of the knee joint
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI) scan
• Joint aspiration

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Total Knee Replacement procedure?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Total Knee Replacement surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia by injection and inhalation is administered for this procedure. The Total Knee Replacement procedure may also be performed under a spinal/epidural anesthesia.

How much Blood will you lose, during the Procedure?

• About 100-300 ml of blood loss may be expected during the procedure
• A further loss of blood may occur as drainage, following the Total Knee Replacement operation
• Usually no blood transfusions are required for a Total Knee Replacement surgery

What are the possible Risks and Complications during the Total Knee Replacement surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes
• The possible risks or complications that may arise during the Total Knee Replacement surgery are:
• Excessive bleeding
• Infection surrounding the surgical wound
• Formation of blood clots
• Anesthetic complications

What Post-Operative Care is needed at the Healthcare Facility after the Total Knee Replacement surgical procedure?

• After the surgical procedure, patients will be sent to an area of the hospital called postoperative recovery area (or PACU)
• A patient’s blood pressure, heart rate, and respiration cycle, shall be closely monitored. Any additional pain associated with the procedure, will also be treated
• The patient is then monitored as in-patient and administered with intravenous antibiotics to prevent infection and analgesics to reduce pain. Medications to thin blood and prevent venous blood clots may also be administered
• Physiotherapy is instituted after a few days
• Individuals are usually discharged from the hospital 5-10 days, after the surgery is performed

After the Total Knee Replacement surgical procedure:

What are the possible Risks and Complications after the Total Knee Replacement surgical procedure?

The possible risks and complications that may arise after Total Knee Replacement procedure are:

• Venous blood clots in the deep veins of the leg
• Pulmonary embolism (fat or blood clots can travel up to the lungs and block a blood vessel)
• Infection in the surgical wound
• Reduced range of motion within the knee
• Loosening of the metal and plastic implants in the knee joint
• Bony tissue can develop outside of the normal knee bones; this abnormal bone growth is called a heterotopic bone. Such a growth is more common following an infection of the prosthesis

What is the Prognosis after the Surgery?

• Following a Total Knee Replacement surgery, most patients have better mobility and lesser knee pain
• But, they should refrain from all activities that greatly stress the joint
• The prosthesis may last for a period of 10-15 years, on an average

When do you need to call your Physician?

Do contact your physician, if you notice any of the following symptoms:

• Pain that worsens and swelling of the surgical wound
• Bleeding or fluid drainage from the surgical wound
• Signs of an infection
• Dizziness
• Muscle aches, headache
• Fever, feeling sick
• Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Total Knee Replacement surgical procedure?

At home, the following post-operative care is recommended, after a Total Knee Replacement procedure:

• Slowly resume regular/daily activities as soon as possible, under advice by the surgeon and physical therapist
• Use a heat pad or warm compress to relieve pain, due to the incision
• Begin by using a walker, followed by crutches, and then a cane, if needed
• Individuals are advised to use assistive devices, such as a raised toilet seat,  a bench for the bathtub, to limit bending at the hip
• Individuals are advised to use handrails, to assist with walking up and down the stairs
• Identify your maximum range of motion and do not exert yourself more than it is necessary
• Avoid lifting or pulling heavy objects
• Resume showering and keep the wound clean and dry after discharge. Gently wash the surgical wound with an unscented soap
• Elevate legs while resting, to prevent the formation of blood clots and reduce the possibility of swelling
• Complete the course of prescribed medication, as advised by your physician
• Take stool softeners to prevent constipation
• Take antibiotic medication to help combat or prevent infection, per advise from your physician
• Use of analgesics to relieve pain
• Avoid all activities that are physically strenuous, such as tennis, skiing, or contact sports
• Resume driving only when advised by your physician
• Individuals are advised to have a well-balanced diet, to promote faster recovery

How long does it normally take to fully recover, from the Procedure?

Normally, it takes about 6 weeks, to fully recover from a Total Knee Replacement procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Total Knee Replacement surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or a physician’s office
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)
• Orthopedic surgeon

The patient is advised to inquire and confirm the type of billing, before the Total Knee Replacement procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA