When healthy, a knee joint has good cartilage (smooth substance that covers the bones that make up the joint), strong ligaments and tendons, well-conditioned muscles, and healthy synovial lining (the membrane that covers all joint surfaces beyond the cartilage surfaces). These structures all work in concert with each other to support a dependable, pain-free joint. Unfortunately, disease and/or injury can disturb the knee joint so that pain, loss of motion, angular deformity and/or instability make life almost impossible to enjoy. The most common kinds of arthritis are osteoarthritis, rheumatoid arthritis and traumatic arthritis.

OSTEOARTHRITIS is the most common form of knee joint arthritis. It usually occurs in association with advanced age, but may also arise in patients who have other family members with arthritis. The cartilage wears away from the ends of the knee bones so that raw bone rubs against raw bone.

RHEUMATOID ARTHRITIS is an immune disorder that causes the synovial lining to destroy cartilage so that bone rubs against bone. Rheumatoid arthritis affects patients at a younger age (at least ten years earlier) than does osteoarthritis. Unfortunately, this disease frequently attacks multiple joints.

TRAUMATIC ARTHRITIS may occur years after joint injuries like fractures and ligament tears. It resembles osteoarthritis in terms of pain pattern and x-ray appearance.

Total knee replacement is reserved for patients who have disabling knee pain that no longer responds to conservative treatments. Conservative treatments include anti-inflammatory medications (like aspirin, ibuprofen, and prescription drugs), nutraceuticals (like glucosamine sulfate), joint injection therapy (like cortisone and hyaluronate gels), knee braces, orthotic shoe inserts, and lifestyle changes. Physical therapy may also be recommended. Conservative measures should be tried as long as they are effective relieving arthritis pain. However, when knee joint pain becomes moderate or severe on a daily basis, in spite of non-surgical treatments, joint replacement is a reasonable option. Furthermore, this degree of knee pain should clearly reduce your ability to perform activities of daily living like walking, stair climbing, and home chores in order for you to be a joint replacement candidate. Your orthapedic surgeon may point out that your joint surfaces rub bone-on-bone to such an extent that nothing other than a joint replacement could help.

Pain is by far and away the most common reason for patients to choose total knee replacement. However, other problems like angular deformity (gross misalignment of the knee) and severely limited range of motion can enter into the list of reasons why you feel disabled by knee arthritis. Patients who declare that pain is the principal reason for their interest in joint replacement surgery are most likely to benefit from and be highly satisfied with their new artificial joint. Patients who cannot describe the characteristics of their knee disability prior to surgery are prone to dissatisfaction with knee replacement. Dissatisfaction is very likely if pain is not their most prominent symptom. Your orthopaedic surgeon is best qualified to help you characterize and understand your knee arthritis disability.

Patients often ask if arthroscopic surgery could help their disabling knee arthritis. Arthroscopic surgery rarely produces anything more than short-term benefit and is usually no more helpful than injection therapy. Some patients are actually made worse by arthroscopic surgery that removes what little cartilage they have, even if diseased. It should be reserved for patients with clearly defined problems like cartilage tears or early arthritis states long before joint surfaces rub bone-on-bone.

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Ultimately, you should undergo a knee replacement only after your orthopaedic surgeon thoroughly examines the following:

• The history of your knee arthritis
• Your past medical history including previous anesthesia and surgeries, allergies, medications andall other health problems besides knee arthritis
• A review of your general health systems so that surgical risks can be minimized (for example, it isimportant to know if your have diabetes since diabetic patients are at increased risk for total joint infection)
• An orthopaedic physical exam and if necessary, some or all of a complete physical exam (like checkingpulses and nerve functions)
• Inspection of x-rays and other anatomic imaging studies (like MRIs), if relevant
• Confirmation that you have indeed failed previous conservative treatments and have end-stage kneejoint disease (joint surfaces are rubbing bone-on-bone)
• A potential need for additional testing like blood tests, knee joint fluid studies (for example, toexclude the presence of infection) and radioisotope studies (bone scans to clarify the exact diagnosis)

It is extremely important that your orthopaedic surgeon explains the benefits and risks of total knee replacement.After the first or additional office appointments with your surgeon, you will be asked to sign a document called INFORMED CONSENT. This document does not force you to undergo the surgery, but it does document in your medical record that serious risks of knee replacement surgery were explained to you and that you agreed to have the surgery performed. Before and after you sign this document you should feel free to ask questions about any aspect of your surgery, recovery and long-term results.

Your surgeon is privileged to provide verbal and written educational concepts to help you understand the benefits and risks of total knee replacement. This web site document from www.snydertotaljoint.com is an example of educational material designed to help patients understand most of the key issues in total knee replacement. However, your orthopaedic surgeon may have different, equally valid information that he or she might want you to consider.

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In general, the best way to get ready for total knee replacement is to be sure that you are either in the best possible health or that your team of physicians (primary care physician, orthopaedic surgeon, and other necessary specialists) knows all about your health problems. Sub-optimal health is not necessarily a reason to forgo recommended total joint replacement, but it must be fully understood and effectively managed in order to reduce the risk of complications associated with this kind of major surgery. For example, diabetes mellitus is associated with up to a five-fold increased risk of infection unless specific measures before, during and after surgery are employed (such as antibiotic inclusion in the bone cement).

• GENERAL MEDICAL AND SPECIALTY EVALUATIONS must be thorough and up-to-date before your total knee replacement. As an example, if you have a history of heart problems, your primary care physician and cardiologist (if you have one) should see you before surgery and review your records and current condition to help prevent heart-related complications. Active dental infections, urinary tract infections and prostate disease are but three examples of infection sources distant from the site of your knee replacement incision that must be diagnosed and treated long before you undergo total knee surgery.
• The CONDITION OF YOUR SKIN is extremely important to help prevent infection. This is especially true for the skin over your legs and around the total knee incision site. Open sores, areas of infection or irritation, swelling and old incisions can increase the risk of problems like infection and poor wound healing. Your orthopaedic surgeon must have current knowledge of the condition of your skin. You must let your orthopaedic surgeon know if any skin changes occur between your last office visit and the day of surgery.
• LEG PAIN can be due to arthritic joint disease, but may also be caused by limited blood flow and/ornerve impulses throughout the lower limb. Patients with peripheral vascular disease (narrowed blood vessels from the abdomen to the feet) can have leg pain that worsens with activities like walking and riding a bike. Patients with spinal stenosis (severe narrowing of the spinal canal) can also have leg pain associated with walking. In both cases, the pain usually goes away after a few minutes of rest, only to recur with another stretch of walking. This kind of pain pattern will continue after a total knee replacement, and can severely limit the benefit from and safety of a total knee replacement. You should discuss any and all leg pain with your orthopaedic surgeon and be confident that he or she has both understood your complaints and examined the pulses, sensation and strength in your legs. Additional tests like noninvasive blood flow studies and EMG needle exams of nerve function may be necessary before surgery. Also, some knee pain is referred from an arthritic hip above. Your orthopaedic surgeon will need to exclude this type of occasional pain pattern before knee replacement surgery is recommended. Usually, a local anesthetic injection into the hip will temporarily eliminate the knee pain in this type of referred pain pattern.
• ALL MEDICATIONS (prescribed and over-the-counter) must be known by your orthopaedic surgeon before you undergo total knee replacement. Some of them like blood thinners (Coumadin) and anti-inflammatories (ibuprofen) must be stopped a week or more before surgery to prevent excessive bleeding. Your orthopaedic surgeon will tell you which ones must be stopped and how long before surgery.
• SMOKING must be stopped before surgery and not resumed after surgery in order to reduce the risk ofwound infection and delayed healing. Recent studies more strongly condemn smoking as a major surgical risk factor than previously acknowledged.
• ALCOHOL DEPENDENCE can result in fatal post surgical complications like delirium tremens (acute withdrawal syndrome) and even an increased risk of infection. Additionally, alcohol dependant patients are a much greater risk of falling and can severely disrupt the healing of skin, tendon, ligament, and bone structures. Alcohol dependence must be diagnosed and treated long before total joint replacement surgery. It must never recur after total joint replacement.
• Your orthopaedic surgeon will provide BLOOD DONATION recommendations. Recent studies suggest thatmostcemented knee replacement patients will probably not require a transfusion after surgery. This is especially the case if patients are in good health and do not have anemia or bleeding tendencies before total knee replacement. Conversely, patients who want to minimize the chance of needing other donors' blood and patients undergoing bilateral knee replacements are but two examples of those who should have special preparation for surgery like autologous (a patient's own blood) donation. This type of blood strategy must be carried out several weeks before surgery. All patients should discuss their concerns about blood transfusions, and understand the risks of surgical and post-operative blood loss.
• Approximately one week before surgery, you will undergo PRE-ADMISSION TESTING at the hospital. Atthistime, you are likely to receive additional instructions about preparing for surgery, as well as helpful advice about surgery, your hospital stay and discharge planning to return home or for extended rehabilitation. A complete history and physical exam, blood and urine tests, x-rays and EKG are performed during this visit. Feel free to ask questions pertaining to any aspect of your upcoming surgery and recovery.

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You will need a lot of help once you go home. If you live alone, special arrangements may be needed for extendedcare (in the hospital rehab unit or extended care facility) and for someone to assist you once you are home. If family members and friends are available to help you after discharge, you should let them know that around the clock assistance may be needed. Cooking, cleaning, shopping, bathing and laundry are sometimes daunting challenges for the total knee patient during the first few weeks after surgery. Most total knee patients are able to go home three or four days after surgery, and progress well at home with visiting physical therapy and the help of family and friends.

Specific preparations at home to ease your recovery include:

• Safety bars and/or handrails in the bathroom, and firmly anchored handrails up and down your stairways
• Elevated chair and elevated toilet seat
• A shower or bath chair with no slip pads
• Repairing loose carpet and floor boards
• Creating a open unobstructed path between every essential place in your house
• Setting up a living area on one floor, if possible

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Typically, you will be directed to PATIENT ADMISSIONS when you arrive at the hospital. After checking in, you willbe taken to a holding area next to the operating rooms where a member of the anesthesia team and operating room personnel will meet with you to prepare you for surgery. Anesthesia options should be somewhat familiar to you based on preadmission education, but will be finalized in the holding area. General anesthesia (you go to sleep during the procedure) and regional anesthesia (a spinal/epidural or peripheral nerve block technique to anesthetize your legs) are the most common types of anesthesia. You will be able to choose, along with the advice of your surgeon and anesthesiology physician, the kind of anesthesia you prefer. At the end of your time in the holding area, you might receive medication to sedate you. Also, you will probably start intravenous antibiotics and have the knee area shaved.

It is helpful to remember these important steps:

• Do not eat or drink anything after midnight during the night before your day of surgery. Necessary medications and insulin shots, under the direction of the anesthesiology physician, may be needed even after midnight. You will receive specific instructions as to what medications should be taken with a sip of water or by means of injection.
• Have someone drive you to the hospital as well as take you home several days after surgery.
• Only bring items you will need the first day or two of recovery such as a toothbrush and glasses.
• Pack a bag in advance of your hospital stay with items you would like to have throughout your hospitalization or additional rehabilitation. Things like important phone numbers, loose clothing, pajamas and/or full-length robe, toiletries, and favorite reading materials should be packed.
• Try to relax and trust that your surgeon and supporting surgical team will do their utmost best to provide you with a comfortable, safe total knee surgery.
• If personal faith is a major coping priority - as it is for most patients surveyed on the importance of prayer - ask your pastor, family and friends, and your surgeon (if both of you are comfortable) to pray for you before and during surgery.

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The surgery will take from one to two hours, depending on the complexity of your knee deformity and soft tissue flexibility. Your orthopaedic surgeon will enter your arthritic knee through an eight to ten inch midline incision. After opening the knee, ligament balancing and deforming bone spurs will be addressed. Bone cutting jigs will be secured to the knee bones so that precise shaping can occur. Only the arthritic surfaces and adjacent bone are removed. The angle at which bone is removed determines the orientation of your new total knee. Realigning your knee so that it is properly positioned between your hip and ankle is critically important for proper function and long term durability. The actual implants will then be secured to your knee bones with cement or through a press-fit technique. Your surgeon will choose which method is best for you.

The materials used in modern total knee replacement have been developed over three decades of laboratory research and clinical application. Even though several different materials and designs are available to your surgeon, most femoral components (applied to the end of your thigh bone) are made out of a highly polished metal while the tibial components (applied to the top of your shin bone) might be made out of the same or a different metal. The space between the two metal components is filled with either a fixed or snap in high-density plastic material. The undersurface of the patella (kneecap bone) is left untouched or replaced with a cemented plastic button.

After all of the implants are secured to your knee bones, your orthopaedic surgeon will test the new knee for balance and tracking of the kneecap. In some respects, these final checks are among the most important steps in total knee replacement. Final adjustments can be done to maximize the range of motion and stability of your total knee. Thereafter, deep and surface tissue layers are securely reattached to allow early motion and purposeful physical therapy. The ultimate motion can be largely predicted by how much your new total knee moves after all tissues are closed during surgery. The actual motion will be achieved if you work long and hard in physical therapy and on your home exercises. It can take up to two years after a total knee is inserted to achieve the fullest range of motion. Patience, a positive attitude, and purposeful exercising are essential ingredients to the best possible total knee result.

In the Recovery Room
At the completion of your surgery, you will be taken to the recovery room. You will stay there for about two hours as your vital signs are carefully monitored and while you regain consciousness. Once your vital signs are stable and you are able to answer questions, you will be taken to a room on the orthopaedic surgical floor. During your recovery room stay, and the remaining days in the hospital, pulses and nerve function will be regularly assessed to reduce the risk of serious complications.

Pain control will begin in the operating room and extend throughout your hospital stay. In the recovery room youmay receive epidural medications (if a catheter was threaded beneath your spinal bones) or narcotic medication through a PCA pump. A PCA (patient controlled analgesia) pump allows you, with restrictions, to receive frequent small doses of pain medication. Usually after twenty-four hours, the epidural catheter or PCA pump will be discontinued so that you can begin using oral pain medications and progress with physical therapy. Compassionate attention to your pain needs will be of great importance during your hospitalization.

Once in the operating room, or during your recovery room stay, a Foley catheter may be inserted to help drain your bladder. Removal of the catheter will be done as soon as possible in order to reduce the chance of bladder weakness and/or infection.

One of the means to reduce the risk of blood clots in your leg veins is to apply soft, mechanical pump devices around your feet or legs. Some patients have these devices applied in the operating room. Most do well with them applied in the recovery room.

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The primary goal of your hospital stay is for you to safely recover from surgery and be ready for outpatient therapy. To achieve this goal you will likely experience a progressive daily routine:

• DAY OF SURGERY: After you leave the recovery room you will be taken to your orthopaedic surgical room. Nurses and other staff will be sure you are comfortable and will check vital signs, peripheral blood vessel and nerve function, and blood tests to be sure you have not lost too much blood. Pain control will be accomplished through the means started in surgery and/or the recovery room. On occasion, pain control requires supplemental doses of narcotics. Great care will be taken to keep you from being "overdosed." The soft devices applied to your legs to prevent blood clots will continue. Many orthopaedic surgeons utilize a CPM (continuous passive motion) machine to help you begin range of motion exercises. You will be asked to do breathing exercises to prevent lung congestion.
• DAY ONE (first full hospital day): Your activity will increase this day. You will be out of bed on several occasions; and you will work with physical therapy in your room or in the physical therapy department. Walker or crutch-assisted weight bearing begins on this day. You will be asked to begin efforts to lift your operated leg a few inches off the bed. Through this effort you will begin to regain quadriceps (frontal thigh muscle group) function, which is critically important to transferring in and out of bed, as well as safe walking. Intravenous antibiotics are usually discontinued by the end of this day. Pain control will progress away from epidural and PCA methods to oral pain medications. Your diet will begin to progress from liquids to solids if bowel function is evident (passing flatus and/or having a bowel movement). The CPM range of motion setting will increase. This device is usually used three times a day. Knee pain may initially increase when the CPM is used, but actually decreases the more you use the device and the more you allow your range of motion to increase. In order to prevent blood clots, and in addition to the mechanical foot/leg pumps, your orthopaedic surgeon may utilize blood thinners. These will continue throughout hospitalization, and often for a week or more after discharge. Blood tests are usually ordered during the first 48 hours after knee replacement surgery. Your surgeon may order a blood transfusion (your donated blood, if available) if your red cell count is too low. Again, you will be asked to prevent lung congestion through breathing exercises.
• DAY TWO THROUGH DISCHARGE: By the second full hospital day, most patients feel considerably better,though they still require pain medication. Fevers, which are common during the first 48 hours after surgery, tend to lessen. This is particularly the case when breathing exercises are performed with vigor. When fevers persist beyond the first 48 hours, blood tests, urine tests, chest x-rays, and additional inspections of the surgical incision are a few of the methods your orthopaedic surgeon may use to track down the source of continued fever. Fortunately, large series of total knee replacements yield deep infection rates less than 1%. Activity levels continue to increase, as do the range of motion and muscle strength in your operated leg. Most patients are ready to go home by the fourth day. Those who have not progressed to the point of safety with walking or cannot perform activities of daily living without a great deal of assistance, may be transferred to the hospital's rehabilitation unit (if available) or an off-site facility for further convalescence. Final blood tests may be ordered before discharge to check your blood count and degree of blood thinning. Typical requirements for discharge to home include the following: 1)the patient must demonstrate a safe walking technique; 2) there must be little or no fever; 3) no more than one other person should be needed for the patient to carry out acts of daily living; and 4) the patient should be able to independently perform strength and range of motion exercises. Hospital staff will confirm arrangements for help at home, nursing visits and physical therapy. Not all of these arrangements may be covered by your health insurance. Discharge planning staff at the hospital can let you know if benefits are restricted or sufficient for home care services.

• YOU must participate in your recovery. No one can do this for you, though you will receive lots of assistance.
• YOU must communicate your pain levels so that adequate medication can be used to help you.
• YOU must progress in your knee exercises in order to maximize the chance of good total knee outcome.
• YOU must follow doctors' orders so that complication risks are lessened. Medications, blood clot prevention devices, blood tests and potential transfusions, exercises, etc. are prescribed to maximize the safety of your total knee surgery and recovery.
• YOU must clearly communicate concerns about any aspect of your care and recovery so that problemscan be addressed.

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Recovery during the first few weeks after total knee replacement ultimately determines the final result! You must follow your surgeon's orders and progress through exercises and activity requirements as instructed. There are several items that must be understood and prioritized to maximize your chance of obtaining the best possible total knee result:

• PAIN is a natural feature of your total knee recovery. Pain medications should be used as directed sothat you can progress with your exercises and activity. Pain will gradually subside and is usually only mild after six weeks. Icing your knee for 20 minutes several times a day can help lessen pain. If you have a Polar Care device, this can be used in lieu of an ice bag. Always place a clean clothe or bandage between your incision and the icing device.
• INCISION care is important to prevent infection or delayed healing. Your incision is securely closed with sutures beneath the skin and staples or sutures on the surface. Do not get your incision wet. Do not disturb dressings unless told to do so by a physician or their designated allied health care personnel. Surface staples and sutures are usually removed 10 to 14 days after surgery. If your first follow-up office appointment is later than two weeks after surgery, a visiting nurse may be authorized to remove the staples or sutures at home. Your orthopaedic surgeon may allow bathing/showering 48 hours after the staples or sutures are removed, and if the wound is well sealed without redness or drainage. Swimming is usually delayed for several weeks.
• ACTIVITIES OF DAILY LIVING will become easier as you progress with your exercises. As pain lessens and your endurance increases, extended walking, house chores, bathing and dressing, shopping and entertainment will become easier and more enjoyable. Patients differ in their ability to progress through rehabilitation. Your experience should not be compared with others. Driving requires sufficient range of motion and muscle strength to help prevent an accident. Most patients are given permission to drive after four weeks. You should get permission to drive from your orthopaedic surgeon. Return to work is possible a few weeks after surgery if knee pain is minimal and you no longer require pain medications. Your orthopaedic surgeon will work with you to permit the earliest possible return to work.
• SWELLING is common after total knee replacement. It should decrease on a weekly basis. Many patients experience enough swelling to make their knee feel stiff for several months. Elevation of the leg can usually ease the swelling, and is recommended during the first several weeks after surgery. Progressive swelling throughout the leg that does not improve with elevation can be a sign of a blood clot. Progressive swelling throughout the knee can be due to bleeding, or even infection. You should always contact your orthopaedic surgeon and be prepared to schedule an appointment if swelling and pain are progressively worse. You may be asked to go to the hospital if special tests are ordered to exclude problems like blood clots.
• DIET improves with time after total knee replacement. During the first few weeks, many patients experience some loss of appetite. However, consuming a balanced diet with vitamin/iron supplements is critically important. Malnutrition is a leading cause of wound complications including infection! If you are unable to progress towards a balanced diet, you should notify your surgeon and your primary care physician.
• EXERCISES at home must be performed with regularity and diligence. Use of the CPM, the help of a visiting therapist, leg lifts and active bending of the knee are some of the most important methods to progress towards a good total knee result. Failure to do these exercises, or failure to progress in strength and range of motion can severely compromise your total knee result. Once a few weeks have passed, you should enhance regimented exercises by extended walking, cycling, swimming and social activities. Exercising can improve your sense of well-being and ability to return to productive living.

Outpatient Physical Therapy
Most patients are able to begin physical therapy at an outpatient center within a few weeks after surgery. It is here that the greatest gains in strength and flexibility can be achieved. This kind of therapy is usually required for around two months, though some patients may require more visits. The physical therapist will help you refine your skills with a walker, crutches, or a cane. Most patients do not require walking aides by six weeks after surgery. The therapist will stretch your knee and use weights to improve your strength. Only a few patients require limited time in physical therapy; the majority needs at least two months of therapy. Most patients would never achieve range of motion and strength goals without the expert help of a physical therapist. The physical therapist should work in close communication with your orthopaedic surgeon.

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Fortunately, complication rates after total knee replacement are low. Some complications are very serious and potentially permanent, while others are bothersome and reversible. Your orthopaedic surgeon, and the team of doctors and allied health professionals with whom he or she works, should utilize the most up-to-date treatments and techniques. Their professional training and continuing medical education should enable them to utilize scientifically validated materials and methods recommended to minimize potential complications and maximize the longevity of your total knee. However, serious complications can and do occur after even the most expert total knee replacement surgery.

• The MOST COMMON complication after total knee replacement is blood clots in the leg veins.
• The MOST SERIOUS complications include death, heart attack or stroke, pulmonary emboli (blood clotsthat travel to the lungs), extensor mechanism rupture (rupture of tendons that let you move your knee) and deep wound infection. The most serious complications are uncommon, and are more likely to occur in patients with chronic illnesses.
• LESS SERIOUS complications include retention of urine and bladder infections, temporary bowel paralysis (ileus), delayed wound healing and prolonged fever.
• LONG-TERM complications include malfunction of the kneecap and surrounding soft tissues, wear of the plastic and/or metal materials, loss of bone structure, loosening of the total knee implant, instability of the knee (slips and shifts too much) and even late onset infection.

• BOTHERSOME PROBLEMS include stiffness, swelling, frontal knee pain, soft grinding and/or clicking, and muscle weakness.

You should realize that the safety of total knee replacement is at an all time high due to careful patient selection for this kind of surgery, improvements in total joint design and materials, better surgical technique, and strategies for risk reduction. The durability of a total knee replacement, particularly when bone cement is used to secure the implants to the knee bones, is greater than ever. The vast majority of patients can expect that their total knee will function well for the rest of their life. This is most likely the case for patients who are 55 or older when they have their surgery done. New materials like Zirconium oxide may allow long-term success even in patients under 55 (see www.smithnephew.com). Furthermore, any patient who follows preoperative and postoperative instructions, exercises caution in their daily activities, and adheres to a healthy lifestyle (no smoking, no abuse of drugs or alcohol, body weight control, accident prevention) can expect a durable total knee result.

Preventing Problems

• INFECTION occurs in less than 1% of first time total knee replacements. Patients at higher risk include those with inflammatory arthritis (rheumatoid arthritis), immune suppression (chemotherapy), diabetes mellitus, previous or current infections in and around the arthritic knee, open skin lesions, and remote sites of infection (dental infections and urinary tract infections). Patients who are at increased risk can undergo a total knee with reasonable safety if their infectious problems are treated and controlled, and if antibiotics are included in the bone cement used to anchor their total knee implants. Patients without any of these problems are at little risk of total knee infection.
  
  Most infections are blood borne from remote sites such as diseased teeth and the urinary tract. Skin infections canalso spread to the region of the total knee. It is thus not surprising that your orthopaedic surgeon will advise you to TAKE ANTIBIOTICS BEFORE DENTAL PROCEDURES AND OTHER SURGICAL PROCEDURES WHERE BACTERIA COULD BECOME BLOOD BORNE TO YOUR TOTAL KNEE REPLACEMENT. Always notify your orthopaedic surgeon if you are undergoing surgical procedures or if any part of your body becomes infected. Preventive and therapeutic antibiotics are essential to protect your total knee from infection.
  
  Signs of a possible total knee infection include:
  • Increasing pain at rest and with activity
  • Increasing swelling, redness or tenderness in the area of the incision
  • Persistent fever with chills
  • Drainage from the incision
  Immediately report any of these signs to your orthopaedic surgeon! Early treatment, and even re-operation to removepus and bacteria can prevent chronic (long-term) infection.
• BLOOD CLOTS are the most frequent complication after total knee replacement. If preventive measureslike blood thinners and foot/leg pumps are utilized after a total knee replacement, the threat of a blood clot is quite minimal. Additionally, death from a blood clot is close to zero risk IF PREVENTIVE MEASURES WERE USED. The signs of a blood clot in the leg veins include:
  
  
  • Increasing calf and/or back of knee pain
  • Increasing swelling in the lower leg
  • Redness or tenderness along the inside of your calf or thigh
  Immediately report these signs to your orthopaedic surgeon. Diagnostic tests like an ultrasound can help detect bloodclots and help your physicians begin early blood thinners to help prevent clot progression and potential embolus to your lungs. A blood clot that goes to your lungs is far more serious than one that is in your leg veins. The signs of a clot to your lungs include:
  • Sudden shortness of breath
  • Sudden chest pain
  • Occasionally chest pain made worse with deep breathing or coughing
  • Occasionally blood in your phlegm
  Immediately report these signs to your orthopaedic surgeon. It is best to be urgently taken to the emergency roomofeither the hospital where your total knee was performed, or to the nearest hospital. Blood thinners are usually started even before definitive diagnostic tests in order to lessen the chance of a fatal outcome.
• TRAUMATIC INJURIES TO THE BONES, TENDONS AND LIGAMENTS OF THE TOTAL KNEE REPLACEMENT can occur ifyou fall. Elderly patients are at much greater risk of falling due to imbalance and slower recovery of strength and endurance. Most falls occur at home when a patient losses balance on stairs. Falls can result in ruptures of the tendons and ligaments in the knee. Falls can fracture bones around the total knee, and even tear open the knee incision. In most cases additional surgery is required. PREVENTION by means of using walking aides and handrails, rapidly rehabilitating to gain strength and endurance, and depending on the help of others is the best way to avoid these difficult problems.
  
  An active lifestyle, often afforded by total joint replacement, will improve your general health and quality of life.In this state of improved wellness, you should be less likely to fall. Be sure to follow your orthopaedic surgeon's warnings regarding dangerous activities and inadequate exercise.

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Once the benefit of a total knee is realized, a more active lifestyle can begin. Self-control and realistic expectations are of paramount importance to long-term durability of the new total knee replacement. Most activities are appropriate, but some are responsible for early failure of a total knee. Activities that are encouraged include:

• Walking, hiking, cycling, swimming, and light weight low-impact aerobics
• Golfing, doubles tennis (without running for balls), ballroom dancing
• Activities that are to be avoided at all times include:
• Any high impact sport or exercise program
• Specifically, basketball, baseball, football, soccer, running, rock climbing
• Activities that can be pursued if done CAUTIOUSLY include:
• Skiing, skating, hunting, weight lifting

How to Successfully Live with Your Total Knee
Remember that a total knee replacement is the installation of a mechanical device into a living joint. As such, it will never feel exactly like your natural knee. You will likely be very grateful for the pain relief afforded by total knee replacement. However, learn to live with some of the mechanical characteristics, and even soft tissue alterations that occur as a result of this surgery. Your expectation of a total knee replacement should be less pain, improved alignment and possibly range of motion, and joint stability. Additionally, you can expect these improvements to lead to greater ease with activities of daily living including a return to approved recreational pursuits previously thwarted by your knee disability. Some of the minor disturbances of a total knee include:

• Clicking of the joint surfaces with stairs and walking
• A sense of stiffness throughout the knee after periods of inactivity
• Numbness on the outside of the knee
• Activation of metal alarms in airports
• Discomfort with kneeling
• Prolonged or even lifetime use of handrails to go up and down stairs

Almost all patients become less aware of these disturbances over time. Survey questions geared to measure satisfaction and improved function yield good or excellent scores in greater than 90% of total knee patients by one year after surgery. In other words, the vast majority of total knee patients are highly satisfied with their "new knee" and relieved to be rid of the pain and limited function they experienced before surgery.

IT WILL BE NECESSARY FOR YOU TO KEEP YEARLY OR EVERY OTHER YEAR APPOINTMENTS WITH YOUR ORTHOPAEDIC SURGEON FOR ROUTINE EXAMS AND X-RAYS. These are needed to allow him or her to detect early signs of potential or actual implant failure. Early detection is often effective in minimizing the extent of revision surgery that may be needed. Unfortunately, too many patients ignore their need for regular follow-up. Worse yet, they fail to detect changes in how the replaced knee feels like swelling, increased pain, or a diminished range of motion. Any of these signs and symptoms can indicate material wear of the total knee, and should be brought to the attention of their

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Copyright 2001 Mark Snyder, M.D.