Your Total Knee Replacement at HSS: What to Expect


Devan D. Bhagat, MD

Attending Anesthesiologist, Hospital for Special Surgery

Introduction

Below is a short narrative outlining the typical experience for a patient choosing to have a total knee replacement. It’s important to understand that this is only one story and that each patient’s experience may differ. There are various medical issues which may require us to modify our practice to optimize each patient’s care at HSS.

The Weeks and Days Before Your Surgery

When scheduling your procedure with your surgeon, make sure you obtain an estimate of how long you will be in the hospital (usually three to five days). Make sure to plan accordingly, considering work schedules, holidays, and upcoming family plans.

  • Clearance: You will be referred by your surgeon to an internal medicine specialist for a medical evaluation and clearance for surgery. If your own internist is on the staff at Hospital for Special Surgery and is available to see you after surgery, then your internist can provide this clearance. This typically includes a history and physical examination, laboratory tests, a chest x-ray, and an electrocardiogram. If your particular medical condition requires it, other tests might be needed before surgery, such as a cardiac stress test.
  • Medications:You may be instructed by your surgeon and/or primary doctor to stop certain medications (such as strong blood thinners like Plavix or Coumadin) several days to a week before your surgery, depending on the medication. A new medication might be added for you to take until the time of surgery, depending on your medical history. In addition, you may be instructed to take some of your medications the morning of surgery even though you won't be able to eat that morning. It is important for you to bring a list (or a bag of pill bottles) including all of your medications to your medical clearance, including vitamins, over-the-counter medications, and supplements (a number of medications and supplements may interact with medications you might receive after surgery).
  • Preparation:During the weeks before your surgery, you may be given the option of donating blood for yourself. Most patients recovering from knee surgery receive at least one transfusion, and this enables you to receive your own blood.

The day before surgery, the preoperative nurse will call you to tell you what time to come in, what medications to take, and by what time you should no longer have anything to eat or drink (usually after midnight). This does not apply to the medications that you have been instructed to take the morning of surgery with a small sip of water. Make sure you follow their recommendations strictly! Otherwise, we may have to reschedule your surgery, which may take a number of weeks.

The Morning of Surgery

On the morning of your surgery, you will arrive several hours before your procedure is scheduled to begin.

  • The “Holding Area”: As you come to the preoperative “Holding Area” on the fourth floor, the preoperative nurse will interview you. You will be asked to change into a hospital gown, be assigned a bed in the holding area and store away your personal belongings; please leave any valuables at home, as you will be asked to remove them before entering the operating room. Your family can be with you during this time. Next, the nurse will insert an intravenous catheter. Although this is a mildly painful procedure, it provides you with necessary fluids and is essential to proceed with surgery. If you are a woman of child-bearing age, you will be asked to provide a urine specimen for a pregnancy test.
  • Preoperative Exam: A Physician’s Assistant will introduce themselves to you and proceed to perform a focused history and physical. The main purpose of this exam is to see if anything has changed since you last saw your medical or surgical physicians. They will explain the risks of the procedure and present to you the consent forms for the surgery, blood transfusions, and any other unique procedures. Your surgeon or one of his/her assisting physicians will come to speak to you and sign your surgical site. This is simply a safeguard to confirm where on your body the surgery will be performed.

Next, you will meet your anesthesiologist. He or she will discuss the anesthetic plan with you and then ask for your consent to proceed.

Anesthesia

The usual anesthetic for a total knee replacement at HSS is regional anesthesia. This consists of a spinal or epidural as well as a femoral or saphenous nerve block. A spinal or epidural is an injection in your low back with local anesthetic that will make you numb from the waist down. This ensures you do not feel any pain during the surgery.

After the injection, a plastic catheter may be placed so local anesthetic can be infused after the surgery to help control the pain. The femoral or saphenous nerve block is an injection of local anesthetic around the nerves going to the knee. These injections help reduce the pain you experience for about 16 hours after the surgery. You will be sedated prior to these procedures and then you will sleep through the surgery.

Additionally, an arterial line will be placed. This is a monitor placed in the underside of your wrist to monitor your blood pressure closely while allowing blood samples to be drawn without the use of additional needles. Regional anesthesia has many advantages, including a decrease risk of blood clots. However, if regional anesthesia is not safe for you, you will receive general anesthesia.

General anesthesia involves being put to sleep with medications that are given through your intravenous line. Once you are completely asleep, a breathing tube is placed in your windpipe and your breathing will be assisted with a ventilator. You will remain asleep and comfortable until the surgery is complete, at which time you will start breathing on your own, the tube in your windpipe will be removed, and you will awaken comfortably in the operating room.

The Operating and Recovery Rooms

  • Sedation/Anesthesia/Surgery: After speaking with an anesthesiologist, you will be taken by a nurse to the operating room. Standard monitors will be placed (such as a blood pressure cuff and EKG leads), and you will be sedated. Your anesthesia will then be administered. The level of sedation is variable, but most people remember waking up in the recovery room after the operation is completed. Occasionally, some patients recall some music or perhaps some tools being used. Be assured, however, that you won’t feel any of the surgery. An anesthesiologist will be with you the entire time. When it is complete, you will be taken to the recovery room and your surgeon will speak with your family.
  • Recovery: In the recovery room, you will fully awaken from the sedation and be placed back on the monitors. One of the nurses will insert a urinary catheter while you are still numb. A drain will have been placed in your knee in the operating room so that the nurses can monitor approximately how much blood is lost after surgery. The staff will send some blood samples to see if you need any transfusions.

At this point, your legs will begin to regain some sensation. This is the point when a machine is attached to the epidural catheter to provide more pain medicine. This machine is called a PCA (patient-controlled analgesia) and has a button which is under your control to give yourself more pain medicine as needed. The pain pump is calibrated so that you won’t be able to harm yourself, no matter how many times you push the button.

Once the recovery room clinicians feel you are stable, they will prepare a regular hospital room for you. They will inform the receiving nurse of your history, and you will be taken upstairs to your room.

Recovering in the Hospital

  • Medication: The first full day after your knee replacement is an important one for pain management. This is the day when you will be started on pills for pain control as the local anesthetic through your epidural is decreased. An anesthesiologist and nurse from the Acute Pain Service will visit you to evaluate and treat your pain. By the second day after surgery, you will be completely transitioned to oral pain medication and the epidural catheter will be removed.
  • Physical Therapy: The recovery process will be an active one. You will likely begin working with a physical therapist the day after your surgery. This is an important part of your recovery that will allow you to get back to your normal activities as soon as possible. Your therapist will evaluate you and progress your therapy over the next few days through dangling your legs, standing, walking to the bathroom, and eventually, walking down the hall.

After two to five days of recovery, you will be discharged home with a prescription for pain medication, a prescription for physical therapy, and a follow-up appointment with your surgeon.

Updated 12/5/2012 by Shawna Dorman, MD


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