What to Expect
Where? Your surgery will be performed in an outpatient setting. Dr. Kimball performs surgery at UVRMC, CUSC, and Timpanogos Hospital. The choice of facility is determined by your schedule, Dr. Kimball’s schedule, and the provider options on your health insurance policy.
How? Anesthesia: Your surgery will most likely be performed under general anesthesia. Under some circumstances a spinal anesthetic may be used. You will be able to discuss these options with the anesthesiologist when you come to the outpatient surgical facility. For cases on the knee, a femoral nerve block will be offered as well. This is an injection of a Novocain-like medication near the femoral nerve in your upper thigh. It has a numbing effect and will diminish the postoperative pain for anywhere from 6-24 hours.
Night before surgery: It is imperative that you have nothing to eat or drink for at least 6 hours prior to surgery. If you are an early morning surgery, then you should have nothing to eat or drink after midnight. Your leg/shoulder will be scrubbed with antiseptic soap at the time of surgery. It is wise to do the same at home the night before surgery. If you have a pimple or other site of infection either on the injury or any other part of your body, Dr. Kimball will likely delay your surgery until that infection is resolved. When in doubt, ask the doctor. Infection is a terrible complication following surgery. It is usually inappropriate to do surgery in the presence of infection.
Day of Surgery: You will be notified by the surgical center as to the time you are to arrive. Laboratory or other tests may be done upon your arrival. You will be notified by the surgical center if special tests need be done prior to your arrival.
The Procedure itself: You will be taken to the operating room. Appropriate anesthesia will be administered. The leg/shoulder will be prepped with antiseptic solution then sterile draped.
Examination Under Anesthesia: For cases on the knee, Dr. Kimball will perform stress tests on your knee to verify and document the degree of instability. He will check for instability of the ACL, the MCL, the LCL and the PCL.
You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia, in which you are asleep throughout the procedure, and spinal or epidural anesthesia, in which you are awake but your legs are anesthetized. The anesthesia team with your input will determine which type of anesthesia will be best for you.
The procedure itself takes about two hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position the new metal and plastic joint surfaces to restore the alignment and function of your knee replacement. Many different types of designs and materials are currently used in total knee replacement surgery. Nearly all of them consist of three components: the femoral component (made of a highly polished strong metal), the tibial component (made of a durable plastic often held in a metal tray), and the patellar component (also plastic).
After surgery, you will be moved to the recovery room, where you will remain for one to two hours while your recovery from anesthesia is monitored. After you awaken, you will be taken to your hospital room.
Your Stay in the Hospital:
You will most likely stay in the hospital for several days. After surgery, you will feel some pain, but medication will be given to you to make you feel as comfortable as possible. Walking and knee movement are important to your recovery and will begin immediately after your surgery. To avoid lung congestion after surgery, you should breathe deeply and cough frequently to clear your lungs.
Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling, such as special support hose, inflatable leg coverings (compression boots), and blood thinners. To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device, called a continuous passive motion (CPM) machine, decreases leg swelling by elevating your leg and improves your venous circulation by moving the muscles of your leg.
Foot and ankle movement is encouraged immediately following surgery to also increase blood flow in your leg muscles to help prevent leg swelling and blood clots. Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.
Possible Complications of Surgery
Pulmonary embolism (PE) is a very serious condition. In brief, it is a clot of blood (thrombis) that breaks loose for where it began, migrates through the venous system to the heart, and is pumped out of the heart along with the blood to the lung. In the lung the blood is replenished with oxygen. The clot or embolism obstructs the vessels in the lung and stops the lung from doing its job. If the embolism is small, its impact may be unnoticed. If it is large, it may result in sudden death. Most pulmonary emboli cause significant symptoms.
Symptoms of a PE include chest pain, difficulty breathing or a feeling of shortness of breath. You may feel as if you are having a heart attack although there may be nothing wrong with your heart. Some emboli are large enough to cause a segment of the lung to actually die (pulmonary infarct). When this occurs, there is often pain felt when filling your lungs by taking a deep breath.
Symptoms may come on suddenly or be of gradual onset. You may feel confused or have difficulty thinking clearly because of lack of oxygen to your brain. There may or may not be associated chest pain. You may or may not have difficulty breathing. Indeed, the symptoms may be vague and difficult to describe.
Who is at risk? Everyone is at risk. Pulmonary emboli can occur in anyone. Blood clots can occur anytime circulation is impaired whether due to an injury such as a bad sprain or fracture, surgery on an extremity, or merely being under general anesthesia for a procedure of any type. Fatal pulmonary emboli have occurred from merely sitting for a long time in a car or on a plane.
For a P.E. to occur a clot must form somewhere. The clot can be in a vein in the calf, the thigh or deep in the pelvis. Often times the clot is silent and you are not even aware that it has occurred. Its presence may only be manifest by the serious complications it produces.
DVT describes the condition when blood clots within a vein thus obstructing the vein. When the clotted or thrombosed vein is inflamed and painful, one may use the term Thrombophlebitis. A DVT is a potentially dangerous condition. If the clot breaks loose from where it formed, it may move to the lungs and cause a Pulmonary Embolism.
Prevention of DVT and Pulmonary Embolism
Prevention of these potentially life threatening conditions is part of almost every condition we treat in Orthopedic Surgery. DVT and subsequent Pulmonary embolism may follow minor injury or surgery, may follow a sprain or a fracture, or may occur with no apparent reason or cause.
Principles of prevention include:
Mechanical means of improving venous circulation (A Reducing the likelihood of a Blood Clot)
- Active leg exercises and early return to function. Nothing works better than active muscle contractions in encouraging good circulation.
- Compression of veins in the legs to minimize pooling or stagnant blood that may lead to clot formation
- Use of elastic stockings to compress leg veins
- Use of elastic wraps to compress leg veins
- Use of mechanical devices that compress veins in the foot and increase circulation These are often used during surgery of all types to aide blood circulation in your legs even though you may be asleep under a general anesthetic.
- Elevation of legs to facilitate blood return to the heart.
Medical means of reducing the incidence or effect of a blood clot
- Use of blood thinning medication
- Other medications
- Use of an “Umbrella” inserted in the major vein below the heart to filter clots and prevent them from getting to your lungs and causing a pulmonary embolism.
How Blood thinners work:
A variety of medications exist which have an impact of the way your blood clots. The use of these medications is often difficult and fraught with potential complications. It is important that your blood clot normally after surgery so that normal healing may begin. On the other hand, it is useful to slow down the clotting mechanism and thus reduce the risk of forming a potentially dangerous blood clot.
Coumadin (Warfarin) is one of the more common blood thinning medications that I use on my patients after joint replacement. Interestingly this drug is also a common constituent of rat poison. The rat eats the drug and then quietly bleeds to death internally. Of course, the medical application of this chemical , if done properly, is to slightly slow down the clotting mechanism just enough to reduce the risk of forming a blood clot yet not so severe that it causes you to follow the fate of the rat.
Unfortunately not everyone responds the same to these medications. Some individuals are very sensitive to these blood thinning drugs and even a small dose will cause severe bleeding while in others a large dose is required to have a desired effect. When prescribing these medications I may do follow-up blood tests to determine how you are responding to the medication.
Infection following surgery is a serious complication. If not treated early, aggressively and effectively, it may lead to failure of the procedure performed as well as chronic disease and even death. An infection occurs when bacteria take up residence either at the site of surgery or some other site and begin to grow and cause damage.
Prevention of Infection:
I worry constantly about infection and its prevention. An infection can create disaster out of what may have been a perfectly executed surgical procedure. I use a number of procedures and processes to try to minimize your risk of developing an infection after surgery. Unfortunately, though infections are relatively rare, they sometimes occur even though all appropriate procedures have been strictly followed.
I do the following to minimize your risk of getting an infection:
- Perform surgeries in facilities where care and attention is taken to assure that the surgical instruments and facilities and clean and sterile.
- Make all possible efforts to assure that the surgical site is properly prepared with antiseptic solution prior to beginning the surgery.
- When appropriate, apply intravenous antibiotics to you (the patient) just prior to the beginning of surgery and, in major joint replacements, continue to administer intravenous antibiotics for 24 hours following surgery.
- Try to be a delicate as possible in handling your tissues such that your bodies healing mechanisms are not adversely inhibited.
- Encourage good nutrition and good general medical care to assure your body is in the best shape possible to ward off potential infection.
- If you appear to have a potential source of infection on your body prior to planned elective surgery, delay the surgery until after the source of infection has been resolved. In some cases this may include taking care of dental or other problems prior to proceeding with elective orthopedic surgery.
Some people are at greater risk of getting an infection than others. These “higher” risk patients include those with diabetes, peripheral vascular disease and those with cancer or other diseases which may suppress your normal immune mechanisms. Some are on medications to treat a particular disease and a side effect of that medication may be to reduce your ability to ward off infections. There are many factors which effect one’s ability to successfully undergo surgery without the complicating factor of an infection.
When performing either a partial or total knee replacement one must always consider the possibility that the implant will eventually fail. Implants can fail for a number of reasons:
- Poor materials:
Concern: The technology behind implants has improved dramatically over the years but from time to time assumed “reputable” companies have produced implants which shortly thereafter have had to be “recalled” because of design or materials problems.
My Response: I use implants for partial and total knee replacement that are manufactured by J&J/DePuy. This company is an industry leader with and excellent track record in producing quality materials. The long term outcome studies in patients with these products are some of the best in the entire joint replacement industry.
- Poor fixation:
Concern: If the implant is poorly fixed to the bone, it will fail.
My Response: I use state of the art systems in bonding your implant to your bone. This may include bone cement or bone “ingrowth” systems to bond the component to your bone.
- Poor Alignment of Components:
Concern: It has been well established that failure rates correspond to the accuracy of alignment of the components relative to the mechanical axis of your leg. Just like the tires on your car, if the alignment is good, the tires last longer.
My Response: I employ the finest Computer Assisted Orthopedic Surgical system in the world to help me put your components in as accurate alignment as is possible. This system has proven to be far more accurate than the mechanical alignment systems that have been in use. This new technology has only been available since mid 2004. This technology has dramatically changed knee replacement surgery and I expect will change many of the other things we do in Orthopedic surgery.
Other factors that may complicate the knee or shoulder surgery include:
Equipment problems, failure of procedure, failure of rehabilitation, or other medical problems. When considering any surgical procedure or treatment, you must always ask yourself if the potential benefits of the treatment warrant taking the risks that go along with that treatment.