David R. Lionberger, MD

Patient Education: How to Plan for a Rapid Recovery

What to Expect in a Minimally-Invasive Total Knee Replacement

Just as the success and joy of a successful travel is planning for the trip, so is knowing what to expect and how to plan for a successful total knee replacement. As you can find in other parts of our web page, minimally invasive surgery (MIS) is designed for patients who are motivated to proceed with recovery at a more rapid rate so as to not delay recovery and waste time. As such, you will be involved in a preoperative training program for conditioning the quad muscles that will be important in your recovery.

Scheduled Visit With Your Internal Medicine Doctor

You will be assigned an internal medicine doctor who is affiliated with the hospital and can follow you during your stay in the hospital. This doctor will run all the tests outlined in the preoperative packet that was either given to you at your office visit or mailed to your home. After making your appointment with this doctor, please contact our surgery coordinator, who can then assign a date for your surgery.

Six Weeks Before Surgery

Starting six weeks before surgery, you will go to a physical therapist for 3 sessions. These therapy sessions are designed to teach you how to condition the quadriceps muscle, which is one of the more important muscles in your recovery. As you're probably already aware, the minimally invasive surgery techniques spare this muscle unlike in the more traditional, old-fashioned central long incision. With a smaller incision, much of the trauma and irritation following surgery is eliminated. But you still have to work hard on having this muscle in great shape when you start your recovery. These exercises should be done at least every other day, and to a point where you really feel it in the morning. Stiff, tight muscles the next day indicate that you have really worked and strengthened the muscle. A 48-hour delay between conditioning exercises helps enhanced muscle strength. Additionally, during these off days, biking, swimming, Nordic track, or elliptical training can aid in aerobic conditioning and stimulate endurance, while not irritating an already arthritic knee. There is another important benefit to the preop physical therapy visit. At that time you will be able to interview and establish a relationship with the therapist as you have with me to make sure they know what MIS means and how to maximize your recovery. It also ensures that there will be no misunderstanding about seeing you no more than one day postoperatively to continue your rehabilitation. We also encourage you to purchase a foam wedge to use during the postop period to help elevate the knee. Although an option, most patients prefer this to pillows as it ensures adequate elevation at the least inconvenience.

Day of Surgery: Before and During the Procedure

Plan for a long wait on the day of surgery. Part of this is starting the evaluation process when you arrive the morning of surgery. More importantly, the antibiotic has to be timed extremely close to the operative time. Unfortunately, there's just no way that I can assure you that our schedule is always going to be within seconds of the estimated time. But because of my obsession to safety and reduction of infection, these antibiotics will be timed extremely close to incision so that we can reach maximum tissue concentration and minimize the likelihood of infections. If you didn’t take your Celebrex before you came, we will provide you with some along with medications such as Lyrica, Hydrocodoine, and Scopalamin patch for nausea prevention. These drugs, along with preoperative pain relievers, reduce pain up to 30-40% if used postoperatively.

I'll be visiting you personally with additional instructions on the exercises that you will start with your family following surgery. Spinal augmented general anesthesia will be administered by the anesthesiologist prior to surgery. The knee replacement lasts approximately 45 to 55 minutes. Computer navigation may add seven minutes to the procedure.

After the Procedure/in the Hospital

You will stay for three hours in the recovery room, after which you will be sent to your hospital room. I do not utilize continuous motion (CPM) machines. They interfere with the success of MIS surgery and are more uncomfortable. Regular exercise postoperatively serves the same purpose as a CPM machine. You should use ice (preferably a Cryo-cuff) and elevation to soothe swelling and stiffness during this time.

You will be asked to start doing leg lifts and heel slides even though the nerve block may make you feel a little weak. These simple exercises, done with regularity and with only one repetition each 10 to 15 minutes, ensure that your muscles don't lose flexibility. We want to ensure continued movement in the muscles, which will maximize all of the technology we are using to provide a rapid recovery for you. A good way to remember when to do the exercises is to turn on the TV, and every 15 minutes there is a commercial break. Use this as a guide.

Pain medications are sometimes feared by patients, but they will aid in your recovery immensely. Make sure to take your medication regularly so that you stay both comfortable and productive. If you're trying to tough out the pain, you're going to miss out on a great deal of opportunity to return your knee back to full function. It is in the first 1-3 days that you need to be the most vigilant in staying ahead of the pain. On the first day, you generally will receive oral, and also if desired, intra-muscular pain medications. The reason for this is that shots start working quicker and provide you adequate pain relief. Additionally, you'll be given Celebrex and Lyrica as well as other multimodal medications for comfort to maintain exercise ability.

The Afternoon After Surgery

The afternoon of the surgery, the nursing staff will come around for an informal stand and walk session around the bed. This has a dual purpose: to make your body used to being up and to keep you limber. On the evening of the day of surgery, we encourage you to use oral pain-relieving medications as needed. Some of these are scheduled, meaning they are given automatically yet any added need will require you to be a demanding patient and request additional relief. Remember you’re our guest and we are there to serve you! Ask for the medications approximately 45 minutes prior to the time in which you think you really need them. These are identical to the medications that you'll have been given prior to surgery and that you will go home on.

Day One – Optional Discharge Day

Two formal physical therapy (PT) sessions are conducted in the morning after surgery to teach exercises and gait training. You may also feel free to walk around on your own. Make sure that when you arise from bed, that you don't do it so rapidly that you feel faint. Asking for a nurse is acceptable and encouraged. Be sure to elevate your leg at all times when not exercising on your foam wedge pillows.

After Hospital Discharge

Outpatient therapy must begin no later than Friday of the week of surgery. We do this with the intent of making sure you have one outpatient physical therapy session prior to the weekend so as to receive your homework. At least three times a day for 30 minutes you need to do stretches and strengthening exercises, much like what you've been doing in physical therapy.

When not exercising, ALWAYS KEEP YOUR KNEE HIGHER THAN YOUR HEART FOR TWO WEEKS. After two weeks, swelling is not as pressing of an issue. However, any fluid build up can stay for months. Here, the best solution is prevention. Ice therapy is helpful. Since there isn't a large incision for drainage to escape from, patients are encouraged to keep their knees elevated more than the traditional midline total knee replacement incision. This is what is most different about a MIS total knee and likewise what allows our patients to recover faster than the traditional longer incisions.

It is especially important at this point in your recovery to involve family and friends. Because you need pain medications to exercise effectively, you shouldn’t drive yourself to the therapist’s office. Therefore, ask a favor during this phase of your recovery and get a designated driver. Remember, our goal is to get you over this surgery in five weeks. Shortening your recovery is in the best interests of all of us!

Weeks 1 to 3 Post-op

Starting Monday after the week of surgery, you’re into your every-other-day physical therapy program, which lasts five weeks or less. The physical therapy starting the week after surgery is usually every other day, generally on Monday, Wednesday, and Friday. In rare instances, this program can be home-based; however, in our experience, home-based programs have generally been less than optimal and take much longer to accomplish the same goal. In the end, your own motivation will be the key factor in your success.

3 Weeks After Surgery

The most important visit is between three and six weeks following the surgery. During this visit, my physician’s assistant or I will obtain x-rays and may make any necessary changes in physical therapy techniques to maximize your recovery. Many times you will have achieved the required 5 – 120° of range where PT can be done at Home. 60% of our patients get there in 3 weeks. We want you there too!

Last Follow up

The final visit occurs at about three months out and is an optional visit. I do want to see you back for an annual evaluation of your total knee replacement every year.

Be assured that I constantly and enthusiastically strive to make this program better for you. Therefore, expect subtle changes along the line. Remember, if any of these discussions generate questions, you can e-mail or phone my staff. Since this is the day of computers, many times questions can be answered electronically. That is not to de-personalize care, but to make us more available to you.

It is certainly an honor and a privilege to work with you during your knee replacement. I look forward to seeing you soon.

David R. Lionberger, MD

--Revised 2010

<< Return to Previous Page