Your Pathway to Recovery: A Patient's Guide to Total Knee Replacement (TKR)

The information below is excerpted from Your Pathway to Recovery: A Patient's Guide to Total Knee Replacement, which can be found in it's entirety at the bottom of this page.

About Total Knee Replacement Surgery

To understand TKR, you should be familiar with the structure of the knee, a complex joint consisting of three bones: the femur (thigh bone), the tibia (shin bone), and the patella (kneecap). When you bend or straighten your knee, the end of the femur rolls against the end of the tibia, and the patella glides in front of the femur.

Total Knee Replacement - Healthy Knee Diagram
Total Knee Replacement - Damaged Knee Diagram
Total Knee Replacement - Post-replacement Diagram

With a healthy knee, smooth, weight-bearing surfaces allow for painless movement. Muscles and ligaments provide side-to-side stability.

A membrane lines the joint. Cartilage acts as a cushion between the femur and tibia and is lubricated by synovial fluid.

With an arthritic knee, the cartilage cushion wears out. The bones rub together and become rough. The resulting inflammation and pain cause reduced motion and difficulty in walking.

The weight-bearing surfaces of a total knee replacement are smooth, as in a normal knee. A femoral component covers the end of the thigh bone, a tibial component covers the top of the shin bone, and the patellar component covers the underside of the kneecap.

Most femoral components are metal alloys (cobalt chromium) or metal ceramic alloys (oxidized zirconium). The patellar component is plastic (polyethylene); the tibial insert component is also plastic (polyethylene); and the tibial tray component can be made of the following materials:

  • cobalt chromium (metal alloy),
  • titanium (metal alloy), or
  • polyethylene (plastic)

Clinical and biomechanical research has steadily refined knee replacement methods and materials. Prosthesis durability can vary from patient to patient because each patient’s body places slightly different stresses on the new knee. However, the average patient can expect to obtain greater mobility and freedom from pain, which will, in turn, improve ability to walk.

Things to Do Before Total Knee Replacement Surgery at Hospital for Special Surgery

Be sure you understand all pre-operative instructions. If you have questions or concerns, please discuss them with your surgeon or call the HSS Patient Education team at 212.606.1263.

  1. Before your surgery, the surgeon’s office staff will make an appointment for you with an internist at HSS who will:
    • Review and/or perform any necessary diagnostic tests.
    • Provide medical clearance for the surgical procedure.
  2. Unless you are told otherwise, continue to take medicines already prescribed by your own physician.
    • Fish oils should be discontinued 2 weeks prior to surgery.
    • Anti-inflammatory medications, nutritional supplements (vitamins, minerals, iron, and calcium) should be discontinued 7 days prior to surgery.
    • Consult your physician regarding aspirin products. Patients with cardiac stents should continue to take their aspirin (81 mg.).
    Extremely Important: Always have a list of your current medications and the dosages, so that the correct medication and dosage can be prescribed for you while you are in the hospital. You should also have contact information for your local physician, and any details on medical information, allergies, or past reactions to anesthesia.
  3. The surgeon’s office staff will also make an appointment for you for pre-surgical testing approximately 7 to 14 days prior to surgery where:
    • The pre-surgical screening staff will perform routine diagnostic testing so you can be cleared for surgery, including taking a blood sample for testing, a urine specimen, and an electrocardiogram (EKG).
    • You should bring a list of current medications and a detailed account of prior medical, surgical and family health history.
    • The nursing staff will request information as part of a comprehensive medical history to add to your patient database profile.
    • The nursing staff will provide instruction on preparation for surgery.
  4. The surgeon’s office staff will make an appointment for you to attend the pre-operative patient education class. The class is approximately 60 to 90 minutes long. During the class, patient educators will:
    • Review the surgical process.
    • Discuss setting realistic expectations, patient safety, mobility, pain management and the prevention of complications (infection and blood clots).
    • Provide instruction on bowel and skin preparation.
    • Provide information about:
      • nutrition and diet restrictions before surgery;
      • the preoperative patient phone call and how patients obtain general pre- surgical information;
      • the staff phone call to the patient the day before surgery with detailed and specific preparation instructions;
      • the time and place to arrive for surgery; and
      • discharge planning
  5. You may be asked to donate your blood for the surgery. If a donation is recommended, the surgeon’s office staff will provide information and schedule one for you, usually 1 to 2 weeks prior to date of surgery. It is important to drink plenty of fluids before and after you donate and be sure to eat a substantial meal prior to your donation.
  6. You may wish to review and plan your post-hospital care with Case Management Services (212.606.1271) before admission. The Pre-Admission Program offers patients and their families the opportunity to receive assistance before the patient is admitted for surgery. This program enables you to begin understanding and planning your hospitalization and your discharge needs in a timely, comprehensive manner. It helps you maximize your options and make decisions in a more relaxed way.
  7. Prepare for your return home from the hospital.
  8. Before your admission, please complete the Health Care Proxy form authorizing another person, designated by you, to make decisions with your physician about your care, should this become necessary.
  9. A nurse from the Same Day Surgical (SDS) unit will contact you one business day prior to your surgical date (Friday for Monday surgical cases) with more detailed instructions.
    All patients must call the hospital’s pre-surgical information line at 212.606.1630 and listen to a pre-recorded message within 48 hours of your scheduled surgery for general instructions and a review of the pre-hospital process.
  10. The night before your surgery and 2 hours after your dinner, administer your Fleet enema.
  11. The surgical area from mid-thigh to mid-calf should be washed with the antiseptic soap solution at the end of your bath or shower on the night before surgery. The solution should be rinsed and removed after application. Specific instructions will be provided through the presurgical screening appointment, the preoperative education class, and pre-operative phone call.
  12. The Call Center nurse will review when you should stop eating and drinking, but realize that it is likely that only clear fluids (no milk products) after midnight (i.e., water, ginger ale, black coffee or tea) will be allowed on the day of your surgery and nothing should be consumed 3 hours prior to your surgical time. A detailed preoperative nutritional guideline is described in this booklet and will be reviewed during the preoperative education class.
  13. For patients who have Sleep Apnea and use a Sleep Apnea device, please bring your mask attachment and a record of the settings you normally use. Please DO NOT bring the CPAP machine. Patients with sleep apnea are generally required to stay overnight in the PACU to be monitored and observed.
  14. The use of nicotine products (i.e., cigarettes, cigars, gums, or patches) has been shown to increase risk of complications following surgery. They can inhibit bone and wound healing by decreasing blood flow to the surgical site. They can also increase the risk of deep vein thrombosis (a.k.a. blood clots). Please discuss smoking cessation with your doctor.
  15. You and your support system will be instructed to go to the Family Atrium on the 4th Floor of the hospital.

After Total Knee Replacement Surgery at HSS

In the Post-Anesthesia Care Unit (PACU), also called the Recovery Room, you may be given oxygen, and your vital signs (respirations, heart rate, and blood pressure) and IV will be monitored. The team will also focus on managing your pain and will begin your rehabilitation. Once in the PACU, the person accompanying you will be provided an update.

To maintain patient privacy, as well as to reduce the risk of infection, PACU visits are limited, but will be facilitated through the Family Atrium patient liaisons.

When the anesthesiologist determines that you are sufficiently recovered, usually a few hours after surgery, you will be transported to an inpatient unit. While most patients are transferred to inpatient units, some remain overnight in the PACU for additional observation and monitoring.

Recovering from Total Knee Replacement Surgery while at HSS – The Beginning of Knee Replacement Recovery

The knee will have a large, bulky elasticized bandaged dressing and may have a thin tube inserted at the surgical site during the operation and attached to a drain and suction device to prevent accumulation of blood around the muscles and bones of the knee. The tube and drain are removed the day after surgery, and the bandage is removed the first or second post-surgical day.

Some surgeons will recommend the use of a continuous passive motion machine (CPM), which helps the knee regain flexion. Members of the nursing staff will position you in bed and help you turn until you are able to move on your own. Regional anesthesia may temporarily inhibit bladder function after surgery. A catheter may be inserted into the bladder to monitor your urinary output.

In collaboration with you and your family, the healthcare team will plan, provide, and monitor your care


Gentle exercises to improve your range of motion can help prevent circulation problems as well as strengthen your muscles. Very soon after surgery, a physical therapist will teach and review your exercise program.

Deep Breathing

It is extremely important to perform deep breathing exercises after surgery to rid your airway and lung passages of mucus. Normally, you take deep breaths almost every hour, usually without being aware of it, whenever you sigh or yawn. When you are in pain or are drowsy from anesthesia or pain medication, your breathing may be shallow. To ensure that you breathe deep daily, the nursing staff will provide you with a device called an incentive spirometer, along with instructions on its use.

Knee Replacement Rehabilitation in the Hospital for Special Surgery

Soon after surgery, a physical therapist will visit you with an exercise program to increase range of motion and strength in your leg muscles.

The physical therapist will assist you in the following activities:

  • Sitting at bedside with your legs dangling
  • Transferring in and out of bed safely
  • Walking with the aid of a walker or cane
  • Climbing stairs
  • Performing muscle strengthening and range of motion exercises with or without the CPM

Your Daily Physical Therapy Session

You will be seen by a physical therapist on the day of surgery or the next morning after surgery. Your therapist will instruct you in your exercise program, which is directed toward increasing range of motion and strength of your legs. For the first few days after surgery, some patients benefit from taking pain medication thirty minutes prior to their therapy session. However, be sure to take your pain medicine when it is due, not only thirty minutes prior to a physical therapy session. You should discuss this with your nurse and/or therapist.

Beginning to Walk

Your therapist or nurse will assist you in sitting up with your feet over the bedside (we call it dangling). You will then stand with the use of a walker and the continued help of your therapist. As soon as possible, you will be allowed to bear full weight on the operated leg and then attempt walking.

As the days progress, you will increase the distance and frequency of walking. Most patients progress to a straight cane within a few days after surgery.

Do's and Don'ts After Your Knee Replacement Surgery


  • Position your knee comfortably as you go about your daily activities.
  • Walk and perform range of motion exercises every day.
  • Use an ice pack if your knee begins to swell.
  • Elevate your leg one hour twice a day if your knee, calf, ankle or foot begins to swell.
  • At home, you can use a grab bar or shower chair for added safety, comfort, support, and stability.


  • Twist your knee. Turn your entire body instead.
  • Jump or otherwise put sudden, jarring stress on your knee.
  • Never put a pillow or a roll directly under your knee. Always keep the knee out straight while lying down in bed.

Using Cryotherapy During Total Knee Replacement Rehabilitation

Cryotherapy, the use of cold to treat your Total Knee Replacement, is an important element of your post-operative rehabilitation. Cryotherapy can help decrease pain while reducing swelling and inflammation.

Swelling is common after knee replacement surgery. It is important to minimize the harmful effects of swelling to enhance your recovery. If you advance your activity too quickly or “over do it”, your operated knee or leg may become more swollen. The more swelling you have in your leg/knee, the more pain you may have, the more difficult it may be to bend, straighten or even lift your leg and it may be more uncomfortable to weight bear. Monitor the swelling and elevate your leg if this occurs. Also, you should continue to pump and move your ankles up and down while lying in bed. Please discuss with your surgeon or physical therapist if you have any specific concerns regarding post operative swelling.

Ice may be in the form of ice wrapped in bags or towels, commercial cold packs or cold compression cuffs.

Pain Medication

  • Take your pain medication as prescribed.
  • To control pain, take your pain medication before the pain becomes severe.
  • If your pain medication seems weak or you are experiencing unpleasant side effects, do not hesitate to call your surgeon’s office.
  • If you are taking pain medication, avoid alcoholic beverages.
  • It is important to notify your surgeon’s office if you require additional pain medications. It will take a few days to mail you a new prescription, so call the surgeon’s office before your supply runs too low. Call when you have 1 week supply to be safe.

If you experience discomfort during your ongoing physical therapy, take your pain medication at least 45 minutes prior to your subsequent therapy sessions. This will allow enough time for the medication to take effect.

The Total Knee Replacement Guidebook

This guidebook is a comprehensive, essential overview of everything having to do with total knee replacement surgery at HSS, from an overview of the procedure and hospital maps to nutrition tips and illustrated physical therapy exercises.


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