Patient and Family Information Handout for Kinematically- Aligned Total Knee Replacement Surgery

Stephen M. Howell, M.D. Diplomate American Board of Orthopedic Surgery Arthroscopic Surgery/Sports Medicine/Joint Replacement Specializing in Disorder...
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Stephen M. Howell, M.D. Diplomate American Board of Orthopedic Surgery Arthroscopic Surgery/Sports Medicine/Joint Replacement Specializing in Disorders of the Knee

Patient and Family Information Handout for KinematicallyAligned Total Knee Replacement Surgery Introduction The goal of total knee replacement is to improve the patient’s function in daily life. Ideally, total knee replacement should decrease or eliminate pain, increase the ability to walk distances, decrease the use of anti-inflammatory agents, and eliminate the use of a cane or walker. Deciding whether or not to have a total knee replacement is based on assessing the activities the patient cannot do. Generally, the ideal candidate for total knee replacement is someone who has difficulty walking short distances, shopping, getting in and out of a car, ascending and descending stairs, and playing recreational activities such as golfing, biking, bowling, playing tennis, and hiking. Knee pain should persist after a trial of anti-inflammatory agents, injections, weight loss, and/or the use of a cane. A patient not ready for total knee replacement is someone who walks several miles a day and has occasional pain in the knee. A quick test to see whether you might need a total knee replacement is to fill out the Oxford Knee Score (www.orthopaedicscore.com/scorepages/oxford_knee_score.html). If your Oxford Knee Score is less than 25 out of a possible best score of 48, then you might benefit from a total knee replacement. Patients often wonder what activities they can return to after total knee replacement. Bicycling, walking, tennis, bowling, golf, skiing, handball, racquetball, and gardening are activities that may be resumed after total knee replacement. Patients may be able to run and jump, however these activities are not encouraged. The timing for total knee replacement depends on the patient’s needs. There is never a rush, as waiting a few months or even a year rarely affects the outcome. You should schedule your total knee replacement after organizing your home, family, and friends to assist in your recovery, and after considering work, vacation, and holiday obligations. To schedule your surgery, please call the office 8 weeks in advance so that we can perform the surgery within your time frame. The process for undergoing total knee replacement can be broken down into several steps, including the initial office visit, scheduling the surgery, preoperative care, day of surgery, recovery in the hospital, recovery at home, and follow-up visits at four weeks, and at 3 months and 2 years if needed. The following discussion answers questions concerning each step and concludes with a section entitled ‘Answers to Specific Questions’.

Timberlake Professional Bldg. 8100 Timberlake Way, Suite F Sacramento, CA 95823 Office (916) 689-7370 Fax (916) 688-5610

Administrative Assistant: Sonja Henderson Email: [email protected] www.drstevehowell.com

Initial Office Visit We should use the initial visit to get to know one another. I need to understand what your needs are and you need to understand what I can accomplish with knee replacement surgery. Together we will assess the severity of your limitations and disability based on your history, physical examination, and a review of your radiographs. Another purpose of the initial office visit is to educate you and your family. Please invite those people you rely on to accompany you as another set of ears can help recall something you might have missed. I will answer all your questions and provide you with a variety of educational materials and my website address (www.drstevehowell.com) which you and your family can review. We will show you a short video that describes a surgical procedure I developed called ‘kinematic alignment’ that naturally aligns your knee to the position it was before you developed arthritis. I first naturally aligned a total knee replacement in January 2006 and have replaced 2500 knees with this technique as of June 2013.

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Several studies have shown that kinematically-aligned total knee replacement, results in a quicker recovery, better function, better knee flexion, better alignment, and better survivorship than the more traditional total knee replacement that mechanically positions the components 1-4,6. One benefit of a kinematically-aligned total knee replacement is that the components can be accurately positioned with use of a minimally invasive surgical (MIS) exposure 4. Patients like the short surgical time (35-50 minutes), short incision, short 1-2 night hospital stay, low blood loss, and small amount of bone removal 1,3-5. Most of my patients that have had a kinematicallyaligned total knee replacement after having a total or partial knee replacement in their other knee that was mechanically-aligned using the traditional technique tell us their kinematically-aligned total knee replacement recovered quicker, has less pain, better motion, and feels more like a normal knee 1,3,4. We will let you examine a life-size model of a knee and the components that will be used to replace your knee. You will learn that the amount of bone we remove to fit the components is minimal, the components are made of plastic and metal, and they are cemented in place. Because the components are made of plastic and metal they may chatter, click, or make noise when tapped together. You may occasionally notice this chatter, clicking, or noise when moving your knee after surgery, which is normal and is not a sign that the components are loose. Finally, we will provide you with an illustrated educational binder that you can take home and share with your family. This handout, the binder, and my web site (www.drstevehowell.com) provide a comprehensive education about knee arthritis, surgery, and post-operative care.

Scheduling the Surgery Surgery should be scheduled when it is convenient for you. Surgery can be scheduled on the day of your initial visit, or after your visit by calling or emailing Sonja Henderson my administrative assistant (916-689-1065, [email protected]). You are more likely to have surgery on the date you request if you schedule 6-8 weeks in advance. Sonja has special expertise in answering any insurance or billing questions.

Preoperative Care • •



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Obtain an MRI that Marshela (916-689-7370, [email protected]) will schedule a few weeks prior to your surgery Schedule an appointment with your family physician, internist, and/or cardiologist and obtain an EKG and medical clearance as soon as you schedule your surgery. The EKG and medical clearance should be faxed to our office (916-688-5610) Obtain fasting laboratory studies at a convenient location near your home one month before surgery. Christina will provide you with the forms (916-689-7306, [email protected]) Continue to take anti-inflammatory medicine, and aspirin until the day of surgery Stop taking anticoagulants such as Plavix (clopidogrel), Pradaxa (dabigatran), Xeralto (rivaroxaban) Coumadin (warfarin) 5 days before surgery unless otherwise directed by your family physician, internist, and/or cardiologist. Review this handout and the educational binder from Methodist Hospital that were given to you in our office. 3



Call 916-681-1672 to attend the free preoperative total joint class at Methodist Hospital (http://www.mercyorthopedics.org/cm/content/tjr_presurgery.asp).

Day of Surgery General Instructions Expect a phone call from the admitting nurse at Methodist hospital the day before surgery (you may also call them directly at (916) 423-6142 up to 2 weeks before surgery) • Follow their instructions • Have an accurate, detailed list of your medications (name, dose & frequency) handy • Please take medications for hypertension, seizures, Parkinson’s disease, indigestion, thyroid problems or depression at your normal time on the day of surgery with a sip of water (no orange juice, coffee, or food). • Remember the time they tell you to arrive at the hospital • Don’t eat, drink (includes coffee and tea), or chew gum starting at midnight before your surgery • Expect to stay in the hospital 1-2 nights. You may go home as soon as you feel peppy. • Bring loose comfortable clothes such as a sweat suit and T-shirt to wear during your hospital stay without elastic on bottom of pant legs. The legs should be loose enough so that they can pulled above the knee to inspect your incision easily. • Bring sturdy, comfortable shoes with non-skid soles. • Bring your toiletries • Do not bring money or jewelry

Report to Admissions Department You will be instructed to arrive at Methodist Hospital (7500 Hospital Drive, Sacramento, CA, 95823 916-423-3000), which is located across the street from our office. Please arrive 3 hours before your scheduled surgery. If you are scheduled to arrive before 5:30 AM, then go to the Emergency Room and they will help you get to the Ambulatory Care Unit. If you are scheduled to arrive after 6:30 AM, then go to the front entrance to the hospital and report to the Admissions Desk. Give the admissions clerk your admission orders. When the admission process is complete you will be escorted to the Ambulatory Care Unit.

Ambulatory Care Unit The preoperative nurse, the operating room nurse, the anesthesiologist, medical consultant, and I will each visit you and your family in the Ambulatory Care Unit before your surgery. The preoperative nurse will start an intravenous line. We have you report 3 hours before the surgery because we need two hours to infuse two antibiotics to minimize infection. Sequential stockings will be applied to your legs to minimize the risk of blood clots. One of the antibiotics (vancomycin) may cause itching or flushing of the upper body. To prevent this we will give you Benadryl, which might make you drowsy. I will ask you which knee we are going to treat and then write my initials above the knee in large letters for everyone to see.

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The anesthesiologist will meet with you and your family and discuss whether you prefer a general (put to sleep), spinal, or epidural anesthetic. We typically use a general anesthetic because the surgery is relatively short (less than 1 hour). Spinal and epidural anesthetics are an option, but they lasts longer than a general anesthetic, which limits your ability to walk on the day of surgery. They are experts at preventing nausea. Please let them know if you are prone to this. The operating room nurse will explain the operating room procedure, confirm which knee is being operated on, verify the antibiotics have been given, and be sure the sequential compression device have been applied. They are experienced and can answer almost any questions. A medical consultant evaluates each patient on the day of admission. The medical consultant is an expert in the treatment of heart disease, lung disease, high blood pressure, and diabetes. Although medical problems after knee replacement are not common, the swift recognition and treatment by a medical consultant experienced in taking care of patients with joint replacement minimizes complications. To help make you and your family more comfortable, I will review the following issues: • I will remind you that we use cement to affix the components to bone like a dentist cements a crown to a tooth. • The setting time of the cement is 10 minutes, which means you can bear weight, and use your knee as soon as you awake from surgery. You could walk home on the day if you weren’t a little sore and tired! • I will remind you that we add antibiotic to the cement to decrease the risk of infection • I will remind you that we use a bolster elevate the leg above the heart to decrease swelling, decrease pain, and increase motion. We have found this is better than a constant-passive motion machine or CPM. • I will remind you that we use sequential compression devices and aspirin to reduce the risk of blood clots. The sequential compression device is wrapped around your calf and improves the circulations in you legs when you rest in bed. • Please remember to pump both ankles to keep the blood circulating after surgery. • You will be given two 325mg tablets of enteric-coated aspirin twice a day for 28 days after surgery. Please let me know if you have an allergy or a history of internal bleeding with the use of aspirin. • I will remind you that we use inject pain medication into your knee before we wake you up to make you comfortable. This will provide you pain relief for the rest of the day and overnight. • We may use patient controlled analgesia (PCA) to make you comfortable. PCA is an intravenous pain medication, which the patient self-administers by pushing a button on a machine attached to the IV pole. PCA may cause some nausea that you can ask the nurse 5







to treat with medication. Most patients stop using PCA the morning after surgery and transition to oral medications. I will remind you that the stay in hospital is typically 1-2 nights and that most patients are discharged home. You may go home when you feel ‘peppy’ and can walk 50 feet with a walker, get in and out of bed by yourself, and climb stairs. I will suggest that you talk with a registered nurse with expertise in planning your discharge from the hospital who will arrange for a physical therapist to treat you either at an outpatient facility or at home depending on how well you are walking. The will also arrange to have a walker delivered to you either at the hospital or at home. I will remind you that I will talk with the family after the surgery is finished. I can either meet the family in the waiting room, or call them (please leave a phone number to call)

Recovery in the Hospital The typical stay in the hospital is one to two nights. Your family can bring food from home if you prefer. You will be offered a glass of wine with dinner! During your hospital stay, a physical therapist, occupational therapist, and discharge planner will assist you. The physical therapist will help you practice getting in and out of bed with a walker, walking down the hall, and going up and down stairs. They will customize the pace based on your general health and ability. They will encourage you if they think you can do more. Once you can walk to the bathroom, walk down the hall, and climb stairs you are ready to go home. During their final visit with you they will instruct you on managing swelling and soreness, progressing your activity at home, preventing falls at home, use of the walker, and care of your incision. The most important tool for reducing swelling and soreness in the leg and knee is to lay flat on a bed or sofa and elevate the foot, leg and knee on 4-5 sofa pillows or a bolster 3 feet above your heart whenever you are not exercising or walking. Less elevation is needed once the swelling subsides. The occupational therapists will provide you with suggestions and guidance to assist you with activities of daily living such as toileting, showering, and dressing that you might find a challenge initially after surgery. The discharge planner will make arrangements to have a walker delivered to you. If you are housebound after surgery, then an appointment will be made for a physical therapist to visit your home. If you are walking well enough to leave your house, then an appointment will be made for you to go to outpatient physical therapy at a location near your home a few times a week. The discharge planner takes pride in making your return to home smooth, efficient, and without stress.

Recovery at Home-The First Four Weeks Wound Care: You may take a shower and get your incision wet when you are at home. A little water running over a DRY incision while in the shower is perfectly safe. The physical therapist or nurse will remove the metal staples at home or in the outpatient therapy clinic 10-14 days after surgery. You may soak your knee in a bath or hot tub 24 hours after removal of the staples.

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Preventing Blood Clots: Remember to take enteric-coated aspirin 325 mg two times a day with a meal until 28 days after the surgery. If you are instructed to take Coumadin instead of aspirin, then adjust the dose based on the INR. The INR is measured with a blood test taken twice a week. • If the INR is less than 1.5, then take Coumadin 5 mg daily. • If the INR is between 1.5 and 2.0, then take 2.5 mg daily. • If the INR is greater than 2.0, then do not take Coumadin until the next INR is obtained. Exercises: Use your knee as much as you want. You are in charge and you know what feels right. Please do only four exercises: 1) Lie flat, and elevate your knee 3 feet above your heart whenever you are not exercising or walking 2) Bend your knee, 3) Straighten your knee 4) Walk frequently as tolerated

Any other exercises are distracting and counter-productive. The goal is to gain MOTION in the first 4 weeks. Begin strengthening only after motion is regained, which typically takes 4 weeks. To help educate you review the video presentation concerning rehabilitation posted on my web site (www.drstevehowell.com). The following recommendations are general guidelines: • Limit swelling in the knee, which decreases pain and improves motion. Lie flat on your back (not in a recliner) and put big pillows under the knee and calf to elevate your knee 3 feet higher than your heart for 2 hours a day (see previous photo). • Use the foot from the other leg to help bend your knee (see previous photo). • Lay prone with the knee and leg off the bed and add a 2-5 lb weight to help stretch and extend your knee (see previous photo). • Set a goal of increasing the straightening and bending of the knee each day. • Short frequent walks are better than long walks. 7

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If you overdo it, then ice the knee and rest for half a day Discard the walker and cane when you feel safe walking without them Don’t be concerned by bruising, blistering, redness, or warmth about the knee as these symptoms are normal after knee replacement. Call me if you move the knee and notice fluid leaking from the incision.

First Follow-Up Visit at Four to Five Weeks If you, your family, your nurse, and your therapist think you are doing well, then call the office and make an appointment to see me four weeks after surgery. When you come to the office you should be able to do the following: • Straighten the knee completely to 0 degrees • Bend the knee when sitting in a chair from 90 to 110 degrees • Walk without the walker or cane • Climb stairs • It’s normal for your knee to still have some swelling, redness, warmth, stiffness, and soreness, however you should be walking better than before surgery.

Answers to Specific Questions How long does a knee replacement last? • Depending on the study, there is an 80-90% chance that your knee will still be working well at 20 years. Your knee will last longer if you keep your weight under control and subject your knee to reasonable activities. When can I drive a car? • You can drive a car after total knee replacement when you feel safe behind the wheel, you are not taking the pain pills, and you can drive in a responsible way. If you are unfortunate and get in an accident the cause should be a judgment error and not an inability to safely maneuver the car. When can I play golf? • You can return to golf at your own pace and when the knee feels OK. Begin putting and chipping, and then progress to the short irons then to the driver. Does bending the knee when it’s swollen ever cause the wound to split open? • I have never seen this. Remember the wound is closed in 3 layers, with two layers of sutures and one layer of staples. This should make you feel confident that you can extend and flex the knee without a fear that the incision will open. When will the pain and swelling disappear in my knee? • It is natural for the knee to stay swollen for 3-4 months as you increase your activity and function. Pain and swelling subsides once the level of activity remains the same for two to three months. When will the warmth and redness disappear in my knee?

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The warmth and redness in the knee may last 3-4 months. This is a natural reaction to surgery and is caused by increased blood supply, which brings a high concentration of nutrients to help heal the knee. Warmth and redness is normal and does not indicate an infection.

Why is there occasionally clicking or noise in the knee when I use it? • Contact between the metal and plastic tibial and femoral components makes noise and does not indicate that the parts are loose or broken. The frequency and loudness of the noise may change with activity, fluid in the knee, and for no reason at all! My suggestion is ignore it. I have heard that I might need antibiotics when I have dental work or other surgical procedures? • The routine use of antibiotics before dental procedures is controversial. A recent review in the United Kingdom concluded that the routine use of antibiotics before invasive dental procedures in patients with arthroplasties of the knee and hip lacks evidence-based information and thus cannot be universally recommended 7,8. On the other hand, in the United States, the opinion prevails that an antibiotic should be given before a dental or surgical procedure for two years after a knee or hip replacement, and that patients with multiple joint replacements, rheumatoid arthritis, and a higher risk of infection should practice the routine use of antiobiotics for life. Feel free to share this information with your dentist. • Let your dentist or surgeon know that you have a knee replacement and they will prescribe the necessary antibiotics. This is a simple precaution, because the act of cleaning teeth may force some bacteria from the mouth into the blood. If the bacteria concentration is high and it goes to the artificial knee, then it can set up a late infection. Will my total knee replacement set off the airport detector? • Yes, it will. Wear loose clothing and allow extra time for a body search after you pass through the metal detector at the airport. Carrying a card that states that you have had a knee replacement does NOT prevent a body search. Is a total knee like a normal knee? • Some patient’s feel their knee is normal while others notice a difference. One patient told me that “my knee replacement feels like my false teeth. It is much better than what I had before, but it’s not as good as the original”. Can I kneel on my knee to do household chores and garden? • Kneeling may make the knee hurt, but will not hurt the knee! Try using a foam pad if kneeling hurts (http://nga-gardenshop.stores.yahoo.net/13-1113.html). Patients that practice kneeling often notice the hurt goes away.

References 1.

Dossett, G. H.; Swartz, G. J.; A, E. N.; LeFevre, G. W.; and Kwasman, B. G.: Kinematic Versus Mechanically Aligned Total Knee Arthroplasty: A Prospective Randomized Double Blind Study. Orthopedics, 35(2): e160, 2012. 9

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Howell, S. M.; Hodapp, E. E.; Vernace, J. V.; Hull, M. L.; and Meade, T. D.: Are undesirable contact kinematics minimized after kinematically aligned total knee arthroplasty? An intersurgeon analysis of consecutive patients. Knee Surg Sports Traumatol Arthrosc: 1-7, 2012. Howell, S. M.; Howell, S. J.; Kuznik, K. T.; Cohen, J.; and Hull, M. L.: Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res, 471(3): 1000-7, 2013. Howell, S. M.; Papadopoulos, P.; Kuznick, K.; and Hull, M. L.: Accurate Alignments and High Function After Kinematically-Aligned TKA Performed with Generic Instruments Knee Surg Sports Traumatol Arthrosc, In Press. Howell, S. M., and Rogers, S. L.: Method for quantifying patient expectations and early recovery after total knee arthroplasty. Orthopedics, 32(12): 884, 2009. Nedopil, A. J.; Howell, S. M.; Rudert, M.; Roth, J.; and Hull, M. L.: How Frequent is Rotational Mismatch Within 0 ± 10 degrees in Kinematically-Aligned TKA? . Orthopedics In Press. Oswald, T. F., and Gould, F. K.: Dental treatment and prosthetic joints: antibiotics are not the answer! J Bone Joint Surg Br, 90(7): 825-6, 2008. Uckay, I.; Pittet, D.; Bernard, L.; Lew, D.; Perrier, A.; and Peter, R.: Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee. J Bone Joint Surg Br, 90(7): 833-8, 2008.

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