The Doctor as Patient: What a Total Knee Replacement is Really Like
Got a bad knee? Thinking about a TKA to get rid of the pain?(TKA means total knee replacement operation; the ‘A’ is for arthroplasty, the technical medical term for a complete replacement). It’s a lot more complicated than that!
I practiced emergency medicine for 40 years before retiring. I handled the rare complications of TKA such as blood clots (DVT or deep vein thrombosis) and joint infection. But I didn’t know much about the usual real experience. Now I do, and the experience as a patient coupled with my medical background proved enlightening. I’d like to share what I learned with you. While my experience appears to have been typical, your progress could be better or worse, and the weeks discussed probably have a 1–2 week range on either side.
When and Why Should You Get It Done?
Don’t waste your money or time on expensive unproven treatments for your knee pain, like stem cell therapy. Even steroid injections in the knee joint are temporary 2 weeks relief at best and they are allowed only every 3 months.
Why should you get a TKA? Basically, severe pain and limping that keeps you from doing things you love, within reason. Waiting until you’re in a wheelchair is too long (but tempting).
When should you get a TKA? The first consideration is your age. A TKA is projected to last 20–25 years depending on your level of activity. So getting it done at age 60 pretty much guarantees you a second procedure in your 80’s, which is not desirable. Waiting until you’re near 70 is the ideal compromise. The second consideration is your pain and level of activity. If you sit in a chair every day, pain may not force you into an early TKA, but if you’re active it might.
Think about what time of year you’ll have it done. You will go nowhere for 4 weeks and need assistance. You won’t be able to resume sedentary work activities like a desk job for 8 weeks, and an active walking job for 12 weeks. For me as a gardener and amateur lilac horticulturist, that meant getting my TKA in November, so I had the mostly inactive winter to recover and do physical therapy.
You won’t be able to drive until you’re off opiate narcotic pain meds (and you will need these), or for 4–6 weeks for sure with a right knee procedure.
What’s It Cost?
The list charge by the hospital was $79,000, not including surgeon and other doctor fees. If you’re paying out of pocket with no insurance, they would discount it to $32,000. Not good for the working poor with no insurance or Medicaid. They would discount it further to $16,000 for a Medicare or a Medicare Advantage plan. You pay 20% for plain Medicare ($3200) or if you also have Medigap or Advantage you pay 4%, ($640).
Home Care Equipment
You’ll need some other equipment at home due to limited mobility and flexibility. Here are the ones that worked for me and were very helpful:
1. A walker — One with 2 front wheels and 2 rear rests works best. Used for 3–4 weeks.
2. A cane — A metal adjustable height one is desirable, with a non-slip grip on the bottom and a soft handgrip on top. Used for 3 weeks from weeks 3–6.
3. A grabber — to grab almost anything from anywhere. Useful for 2 weeks.
4. A dressing tool — basically a three-foot dowel rod with plastic-coated metal hooks on each end. This is great for helping with clothes dressing for 2–4 weeks.
5. A sock aid — a wonderful, simple invention to stretch and pull-on socks when you can’t bend your knee much. Useful for 6–10 weeks. The only alternative is to have your caregiver do your socks every day. Or have cold feet.
6. A shower seat — helpful for a week or two.
7. A toilet seat riser — might help for a few weeks depending on your toilet. Standard toilet seat height is 16 inches, the new Comfort height toilet seat height is 18 inches, and might be adequate as it was for me (though a couple more inches would have been welcome for my 6'2" height). People under 5'4" prefer the standard toilet height. For the surgery you can add an enhanced height seat for 2–3 more inches, a riser that adds 2–4 inches, a riser with a seat that adds 4–6 inches, or a frame commode that can go to 23 inches.
8. Ice packs — but not the useless continuous ice-water machine they have in the hospital. Commercial ice packs are much more practical, especially the bigger ones with re-freezable gel in them. The round collapsible ones that are 9 by 11 inch and fillable with ice work fine too, but they’re a pain to constantly refill and the ice goes quickly.
9. You won’t need a wheelchair unless you are over 85 years old, and then only for a week or two.
Preoperative Questions
Your preop talk with your surgeon or their physician assistant (PA) or certified nurse practitioner (CNP) is important. Come with prepared questions. I left thinking I’d be up and about with mild pain in a few days, and back to normal in a month. Maybe they thought I didn’t need much information because I was a doctor, but I felt unprepared for the real course and the amount of pain that I experienced. Don’t you be surprised: read what I’m going to tell you.
Robotic Surgery?
You say you want the robotic type of TKA? Your insurance might not pay for it. It probably adds at least 5 figures to the total. Just so you know, the robot is used to assist the surgeon, it doesn’t do the surgery. Instead, it’s programmed with a preop CT scan of your knee to measure every bone surface to the millimeter, and prevents inadvertent slippage of the surgeon’s tools, which can happen for 1–2 mm in a small percent of cases. So far, we think it can improve the acute recovery period, but long-term outcomes have not yet been proven to be better, which is why some insurances won’t pay for it. But if you get to use the robot, make sure you use a robotic fellowship-trained surgeon; these are complicated devices that take expert instruction and practice to use safely.
Choosing an Orthopedic Surgeon
Speaking of surgeons, how do you choose your orthopedist? I’ve always thought a doctor reaches their peak ability at about age 40, combining knowledge, training, and experience. There is a rapid buildup of ability until that age, and a very slow fall off after that age that becomes more rapid after age 60.
I suggest you choose an academic medical center or at least a large community teaching hospital, and a board-certified orthopedic surgeon, fellowship-trained if using a robot, preferably a younger surgeon with the most up-to-date knowledge and training. But gave them a few years in practice to ramp that expertise curve up. Avoid the older, big-name doctors; too many of them rely on their name and reputation and don’t keep up with the most recent knowledge and training.
Dental Care
You’ll need to obtain a certification from your dentist 6 weeks before surgery that your teeth are in good shape with no signs of tooth abscess or significant gum infection. Those things could lead to the dreaded complication of a joint infection when bacteria spread through the bloodstream. Get your teeth and gums in shape months before the surgery.
Preadmission Testing and Preparation
Two weeks before surgery you’ll need preadmission testing (PAT), including a history and physical exam, heart tracing (EKG), chest x-ray, and blood tests. You’ll also get a nasal swab to test for drug-resistant staph (MRSA), a frequent cause of joint infections. If it were positive, you would use a nasal antibacterial ointment for a week. And these days you’ll also got a COVID-19 test 3–5 days before surgery followed by quarantine. A positive one would cancel the operation.
Two days before surgery you scrub your body and especially the operative knee with a special antibacterial soap called chlorhexidine (Hibiclens®). You may also have to modify your usual medication regimen, such as stopping ibuprofen to reduce the chance of bleeding during surgery.
And pack a bag: the surgery still requires one night overnight in the hospital for most people.
Arrival for Surgery
Really, this is the easiest part for the patient. You need to arrive several hours before your scheduled surgery time. There will be lots of paperwork and clothes changing and waiting for your preop bed to be ready. The preop nurses are friendly and very professional and put you at ease.
Anesthesia
Then the anesthesiologist comes and talks to you about your choices for the surgery. Naturally, they have their preference and will gently sell it to you. Here’s a hint: do whatever they tell you. They’re the pros and have lots of experience, probably more so with whatever process they suggest to you.
Rarely you might get general anesthesia. Usually you’ll get a spinal block, a better option, done quickly and slickly and nearly painlessly, and it works great, numbing you below the waist and, of course, temporarily keeping you from being able to move your legs. They might also inject some long-acting morphine in the spinal canal during surgery. This can make you a bit dizzy for 12 hours but helps with postop (after-surgery) pain and increases the effectiveness of sedative medication during surgery.
You might also get (and should ask for) an obturator nerve/adductor canal block under ultrasound guidance, a very skilled procedure. For this, they inject a long-acting anesthetic in a spot on your middle inner thigh where the nerve to your knee and lower leg goes; it lasts for 48 hours and is very effective for that time.
And finally, during surgery they will likely inject a long-acting anesthetic in your knee joint that stops pain and lasts for 48 hours.
The Surgery
The surgeon will also see and talk to you and have you draw a marker over the knee to be operated on so that there is no mistake.
During the operation, you will usually be given so-called conscious sedation medications, primarily propofol and a benzodiazepine sedative. This will leave you with no memory of the procedure, but you will still not need to be intubated or have your breathing assisted except with oxygen. And hopefully no foley catheter (a tube up the urethra to constantly drain the bladder), which was routine in the past. Nice.
Recovery After the Operation
You’ll wake up, alone these days (no visitors due to COVID), in the post-anesthesia recovery unit (PACU, old name of the recovery room). The nurses are pleasant and solicitous. You’ll likely have no pain though some might have nausea. You can call your family, and after a few hours you’ll go to your overnight room on a hospital orthopedic unit.
The floor nurses and aides are very pleasant and well-trained, again very attentive and helpful. You’ll be able to use the walker to walk to and use the bathroom that first night. But you probably won’t sleep very well, and they apparently don’t like to give sleeping pills anymore, for fear of inducing addiction, I suppose.
The day after surgery you should have no pain and won’t need pain meds, and you might even mistakenly think that you might be able to go back to your usual life the next day. Very misleading. You’ll go home with your ride using a walker, slowly, able to handle one or two single steps into the house.
Visiting Nurse
Around days 3–4 after surgery, the home nurse visits and makes sure you’re doing well and have what you need. They’re the one who certifies your medical condition and authorizes the at-home physical therapy. Mainly useful if you get sick or have a complication.
Physical Therapy (PT)
The physical therapist comes to your home on day 3 or 4. PT is the most important thing during the next 12 weeks for your successful recovery. The first 3 weeks are at home, the next 9 will be at an outpatient PT center. This will be oriented towards improving knee flexion, then later to strengthening thigh muscles.
About 6 weeks postop for the first time at PT you will be able to peddle a bicycle in a full circle. At 7 weeks you’ll start on more aerobic exercise.
PT clearly makes the thigh, lateral hip (where the thigh muscles attach), and even the knee hurt more, but it is all to build up muscle strength and increase knee flexion.
Maximum thigh strength effect and thigh pain reduction will be obtained by about 12 weeks. But too-early resumption of vigorous physical activity for too long can cause your leg to ache for the rest of the day and maybe the next one too.
The Way the Leg Looked
Lots of swelling and bruising will be present from the beginning. This will be over the knee, of course, but also over the outside of the lower leg and the inside of the thigh. The thigh bruising is from the surgical tourniquet used for 60 minutes during the operation. Swelling and bruising travel down the leg with time.
At two weeks you ‘ll have a follow up appointment at your doctor’s office, usually with the PA or CNP. You’ll have an ugly 6–8 inch vertical scar across the knee with lots of scabbing, and still lots of swelling and bruising. This will be normal.
At 6 weeks, all the bruising will be gone and the surgical scar will have lost its scabs and be healed, though the scar will be a bit thick and rough on the upper end, a common occurrence. The knee will still be moderately swollen through 7 weeks.
By the end of the 8th week your surgical scar will be smoothing out, but the knee joint will still have a moderate amount of fluid and warmth. Swelling will be gone everywhere except the knee joint itself.
At 13 weeks the scar will be smooth and look good. It will be reddish or purple for a year.
Pain Relief
You will have so little pain in the hospital for the first 48 hours that you might think you’ll only need acetaminophen (Tylenol®) and the prescribed celocoxib (similar to ibuprofen) for pain. You might even decline the offer of a few days of some stronger pain pills. Don’t make that mistake.
It’s good for doctors to experience the misery of a major operation (like me). It makes them much more sympathetic to their patients’ experiences. The pain in my knee and leg started about 56 hours after surgery in a dramatic and severe fashion. My wife will attest to how irritable it made me. I used the few days of prescribed hydrocodone (a medium-strength oral opiate analgesic for acute pain), that I didn’t think I would need, with little relief, and quickly switched to some oxycodone leftover from a gallbladder operation (generally considered the strongest oral analgesic for acute pain), an option most patients don’t have without begging their doctor or even knowing it’s available.
I’m surprised the doctors didn’t insist on prescribing a selection of powerful opiate narcotics for more time, but I understand the current pressure they are under to prescribe the least powerful analgesic for the least amount of time. Perhaps patients should be screened for addictive potential, which is present in perhaps 10% of the population. That would let the other 90% get more adequate pain relief, while the 10% would be no worse off than they are now.
By 2 weeks you will have much less knee pain, but your thigh will still have bruising and swelling from the intraoperative tourniquet and lots of local pain. At that point you might manage to switch from oxycodone to hydrocodone.
At my 2-week follow-up office visit, the PA was surprised that I hadn’t wanted hydrocodone at the beginning and gave me a two-week supply (which I stretched into 4 weeks before my pain decreased enough to stop it). And I certainly needed the stronger oxycodone for the first 2 weeks, which I was not given.
During the third week postop you might have more knee pain, especially just above the kneecap where the rectus femoris muscle, part of the quadriceps, had been vertically cut for the operation. This pain can persist for months especially going down stairs.
You will have lots of pain at night and consequently sleep will be in limited spurts of a few hours. The days will be repetitive and boring. The pain will limit your appetite and likely cause a temporary small weight loss (12 lbs for me, regained by 8 weeks). You might have thought you’d catch up on reading or writing or TV watching, but you won’t have the focus and energy for 2–3 weeks because knee and thigh pain will never be gone, ranging from a 2–8 on the 10 scale. But you will finally be able to go downstairs with a cane. For the first time, you’ll realize that the knee pain that caused you to get the operation is really gone, and you might be able to skip a hydrocodone dose.
By the end of 3 weeks, knee pain itself will be minimal though worse with exercise, but thigh pain will be bad by day’s end, likely due to your weak thigh muscles both from years of limping and the surgery. Ice will help the pain, and you can probably get down to 2 hydrocodone per day.
The fourth week will have waxing and waning significant lateral hip and thigh pain, perhaps not relieved with heat, cold, or pain meds, and often worse with a soft chair and in a soft bed. You might have to temporarily stop exercising. You might be sleeping poorly and have fatigue and nausea. But over time (days to a week) it will all improve dramatically as you have decreasing swelling. For the first time you will start feeling as you expected to feel. You might have your first night without having to use hydrocodone, though sleep will be interrupted often and might require ice and elevation for relief.
At 5 weeks, you should be able to get off the hydrocodone and all opiates. Celocoxib will be done and you can start using 400 mg ibuprofen every 6 hours instead, which should be adequate when combined with ice and elevation. Knee pain will be mild, but thigh and hip pain will still be moderate.
By the middle of the 7th week thigh and hip pain will be mild in the daytime but still might interrupt your sleep once nightly. By 8 weeks your knee should ache somewhat only after exercise.
By week 11 pain should be much less, with ibuprofen use down to twice daily.
By 12 weeks your thigh and hip pain should be 90% gone, though worse after too much activity. Knee pain should be only at the top of your kneecap, primarily with stepping downstairs.
Blood Clots and Infection
The leg will look so bad the first week you might actually be concerned about the possibility of blood clots. It can be scary. Just call and talk to your doctor or the on-call doctor who can help reassure you or tell if there is any cause for concern.
You will likely be on aspirin (if you’re low risk) for 35 days to prevent blood clots; stronger blood thinners might be used for those with more risk factors for clotting.
You’ll usually be given antibiotics during surgery and for a week after, to try to prevent any possible infection of the skin wound or the knee joint. Standard practice. Of course, the joint will be swollen and red and painful for 2 weeks, all potential signs of infection, but at least there should be no fever and no operative wound drainage to otherwise suggest infection; still, a tough call for a normal person.
Ice Packs & Elevation
You’ll continuously use lots of ice packs and practice leg elevation the first ten days. This will reduce swelling some and help control the pain. Ice and elevation will be mainstays for many weeks, likely becoming a nightly ritual when sleep is interrupted by pain through about 8 weeks, as well as being used after exercise for 6 weeks. By 8 weeks you should be down to using ice during the daytime only twice per day. By 11 weeks the ice will be done.
Sleep
You will sleep very poorly the first 10 days; usually no more than 2 hours at a time, only 3–5 hours at night, and 2 hours during the day. You will likely be up icing and elevating every night. At my followup visit at 2 weeks I asked the PA for sleeping pills but was told they don’t use them anymore (again, for fear of causing addiction). Big mistake, in my opinion.
At 4 weeks you’ll be sleeping a bit better; sometimes a firmer bed mattress can help. At 6 weeks you should be sleeping up to 6 hours before the pain might awaken you for good, but sometimes you’ll still need ice and ibuprofen in the middle of the night. But by 8 weeks you should be able to sleep 6–7 hrs, and by 8 weeks for 7–8 hours, with occasional awakenings for ice.
By 11 weeks you should expect to be finally sleeping about normally. You’ll likely still need to use a pillow between your knees if you sleep on your side.
Mobility
After about 4 days you’ll be able to go up and down stairs once a day, one at a time, with someone else carrying the walker. You’ll use a walker to get around the first 10 days, but this will quickly improve by 2 weeks to using just a cane. You won’t be able to drive. Your limp will be worse than before surgery but if you had locking of the knee joint before surgery, you won’t now.
At 4 weeks you’ll be able to walk some without a cane, do stairs well enough one step at a time, and help with minor chores. But you’ll discover that walking without a cane leads to more thigh and hip pain, so you’ll probably go back to the cane.
By the end of 5 weeks, you’ll feel like putting on regular clothes again. You can walk one-half mile (slowly), and only use a cane for stairs and long walks.
Early in the 6th week you can start alternating stairsteps with a cane, though going down will still be a single step at a time due to pain. By the end of 6 weeks, the cane will be gone, even for stairs. Except after exercise, your limp will be gone when you think about it and gone for real by 7 weeks. By 8 weeks you should be walking normally.
By 10 weeks you can walk a mile without difficulty, and perhaps do some outdoor gardening.
By 11 weeks you can start walking fast and including up and down paved hills for a 1 or 2 mile course.
By 12 weeks you can do normal outdoor work for 1–2 hours, or whatever you could do before surgery but without the knee pain.
Knee Range of Motion
Extension of the knee to nearly 180 degrees (a straight leg) was the initial goal, easily fulfilled in most cases. But flexion of the knee is another thing.
At 2 weeks knee flexion might be only 70 degrees due to all the swelling. Normal knee flexion for those over 60 is up to 130 degrees, and the postop goal is 100 degrees at 6 weeks and 120 degrees at 12–14 weeks. This will only happen with regular physical therapy.
Here’s my postop record of maximum knee flexion:
2 weeks: 70 degrees
3 weeks: 80 degrees
4 weeks: 85 degrees.
5 weeks: 95 degrees
6 weeks: 100 degrees
8 weeks 110 degrees
12 weeks: 115 degrees active flexing and almost 125 degrees passive forced flexion
You should be aware that the moving of the plastic-backed kneecap over the new metal knee joint will often cause a vibratory and auditory clicking when you bend the knee. It gets better but never really goes away.
Skin Changes
Two cutaneous skin nerves exist at the inside medial aspect of the knee which give skin sensation that extends across the midline. Unfortunately, these nerves are cut by the vertical incision across the knee joint.
So as a result, at 3 weeks you will notice the inside of your knee medial to the surgical incision is hypersensitive to light touch of clothes or sheets, an unpleasant pins and needles sensation. The outside or lateral side will be numb over a 2 by 8-inch area.
Over the next 8 weeks you might have to cover the sensitive knee skin with a cloth or ace bandage to keep clothes from painfully rubbing it.
By 11 weeks the inner knee skin should be less sensitive, but it will be still numb on the outside. This may will be permanent. Undesirable, but not a deal-breaker.
Driving a Car
At 4–5 weeks you should be able to begin driving a car for a short distance for 15 minutes before the knee flexion causes too much pain. By 5–6 weeks you will likely be able to drive for 20–30 minutes at a time or sit as a passenger with your knee bent for up to one hour. By 7 weeks you should be able to drive for two, 1.5 hour stretches in a day.
By 10 weeks, driving will be normal, though getting in and out of the car will remain a bit slow and feel stiff; but if you’re over 65 this was probably true before the surgery as well.
Summary Comments
For me, it felt like hell for the first 4 weeks, but it did end. But my recovery had not. At 6 weeks, I saw and talked to my surgeon for the first time since surgery. I can see why they wait until this time; I would not have been very happy before then.
By 12 weeks, you’ll feel pretty much back to baseline. I saw my surgeon for the last time. She was happy, and so was I. It’s not a normal leg, but it never was and feels 90% there. Her skill and the technical procedure have wrought an amazing medical improvement that can prevent crippling in the elderly, and she, her team, and our medical system deserve great thanks for this wonderful restoration of function and abolishment of pain.
There are limitations. You can never kneel on that knee again, as that kneecap is now lined underneath with breakable plastic rubbing on metal. Super active sports like skiing, basketball, and racquetball are out. Running is not likely but hiking and gardening are possible.
Bottom line: this is a very major surgery. Get it only if you need it, but if you need it, after 3 months of recovery it will have been well worth it.
