Knee Procedures

After undergoing Total Knee Replacement:  These are some of the important directions to be aware of:

Dr. Kirt Kimball Total Knee Discharge Instructions

The following discharge instructions are from specific from Dr. Kimball.  These instructions are general guidelines.  Your individual needs may vary depending on your condition.  Please contact Dr. Kimball’s office for more information if needed.

Blood Clot Prevention:

You have been prescribed a medication (Aspirin, Eliquis, Xeralto, Lovenox, or Warfarin) to help reduce your risk of getting a blood clot. It is important you take this as prescribed for the duration of the prescription. Along with taking your other medication, movement is one of the best ways to prevent blood clots. Continue to do ankle pumps while laying and sitting. Walk every 1-2 hours throughout the day, while awake. 

Signs of a blood clot:

• Swelling in thigh, calf, or ankle that does not decrease with elevation. 
• Pain, warmth, and tenderness in calf, back of knee or groin area. 
• Blood clots can form in either leg. t
• If you have any of these symptoms, please reach out to your surgeon. 
• Shortness of breath or chest pain could represent a pulmonary embolism.  This is a blood clot that moved to your lung and represents an emergency (911).

Managing Pain, Discomfort, and Side Effects:

You are going to experience a fair amount of pain. You have been prescribed medication to help in the management of pain and inflammation.  Getting pain relief will help you rest better and do important exercises so your new joint will heal properly.  Follow the instructions on the prescription label and track the use of your pain medication in a log.  It is important to remember to take pain medication before activity and bedtime.  When your pain has been controlled, you may slowly decrease the amount of medication you are taking (such as – taking one tablet instead of two; or increase the time between doses).  Narcotics should be the first medication you taper off.  Only take the medications prescribed in addition to your regular medications for other medical conditions (ie. Hypertension/diabetes/etc)   If your medication is not effectively managing your pain, please try:

• Applying ice to your incision or painful areas
• Lying flat and elevating your leg above your heart
• Changing your position frequently
• Using distraction, try doing things you enjoy– reading, watching TV, or listening to music

DO NOT drive or consume alcoholic beverages while on narcotics.  

Pain Medication Refills:  keep track of pain medication quantity. You must give the office 24-hour advanced notice before you will run out of medication.  Make sure to plan ahead, especially for weekends and holidays, as it is difficult for your surgeon to prescribe medications afterhours. Have your medication and pharmacy information ready when you call.  Current State Law severely restricts all physician’s ability to prescribe pain medication in an attempt to curtail opioid addition.  Although well intended, these restrictions sometimes make it difficult to take care of patient’s needs. 

Constipation is a common side effect of opioid pain medication.  Continue taking stool softeners and follow the Step by Step Bowel Care Guide for After Surgery.  It is a great resource to help prevent or manage constipation.  If you have not had a bowel movement within 7 days, please contact your surgeon.  Stop stool softeners if you begin to have loose stool or diarrhea.

Nausea can be a side effect of pain medication.  Make sure to eat something before taking pain medications to help decrease the risk of nausea.  If you are experiencing nausea, start refueling your body by drinking small amounts of clear liquids such as 100% fruit juice or broths.  Bland carbohydrates are easy to digest and will typically not aggravate the stomach when you are feeling nauseated.  Carbohydrate options include crackers, bread, bananas, applesauce, or Jell-O.  It is my routine to prescribe an anti-nausea medication in anticipation of this possibility.  

Mild dizziness is a common side effect of pain medication.  Be careful as you walk or climb stairs. Notify your surgeon if the dizziness persists and it is keeping you from walking and being active.

Breathing deeply will help prevent a respiratory infection following surgery.  Take deep breaths every hour until you are back to your usual level of activity. If you were sent home with an Incentive Spirometer, use it 10 times each hour while you are awake and you follow-up with your surgeon. 

Incision Care:

With any surgery, there is risk of infection. You can take action to minimize this risk.  Good handwashing is the most important thing you – and those who care for you – can do to prevent infection.  Wash your hands before you touch the area where your surgery was done.  Please keep dogs, cats or other pets away during your recovery.  They represent a significant source of bacteria that can cause infection.  Take extra precautions in keeping bedding and bed clothing extra clean and especially away from pets or other sources of contamination. 

Knee Surgery

Your incision will be covered with a waterproof dressing and covered with an ACE elastic bandage when you go home.  You may remove the ACE elastic wrap 24 hours after your surgery to shower. It’s okay to let water and soap run across the waterproof dressing.  Rinse clean and pat dry. Rewrap leg with ACE elastic bandage to help with compression. No lotions, ointments or creams, should be placed on or around the surgical site or dressing. No soaking or submerging in water such as hot tubs, bathtubs, swimming pools, for 4-6 weeks or until the wound is completely healed and no scabs are present. 

You can expect to have some redness and warmth around the incision site and swelling extending above and below the joint. Bruising and discoloration around your operation site is normal.

Change your dressing if the edges become loose and water seeps into it while showering. Some drainage is normal and can be expected. If your dressing becomes saturated and there are multiple large dark spots migrating to the edges of the dressing, then you need to change your dressing. Using the ACE bandage for compression can help slow the bleeding and drainage. The drainage should slow down and stop within 24-48 hours. If the drainage persists, or you notice a significant increase in redness or warmth, please call your surgeons office immediately.  In most cases, your original water proof dressing is still in place when you see Dr. Kimball at your first post op office visit.  

Swelling:

Swelling is to be expected after a joint replacement.  It can cause increased pain and limit your range of motion.   Swelling is best controlled by following the R.I.C.E. Method:

REST – Getting enough rest will help your body heal and reduce swelling.

ICE – It is recommended to apply ice for 20-30 minutes every 1-2 hours, after physical therapy/activity, and before you go to bed.  Ice can help to reduce and minimize the internal scarring process. Always make sure there is a something between your skin and the ice to help prevent an ice burn. Place ice packs on the outside of your clothes, or place ice packs inside of a clean pillowcase or dish towel before applying it to your joint.  

Compression – Using an elastic bandage or compression stockings keeps extra fluid from collecting in and around your joints. You will be using an ACE wrap to help dress your knee incision. This will help with swelling. This should be snug but not too tight. The ACE wrap should be changed daily in order to check your skin and can be hand washed with a mild detergent and hung up to dry if it becomes soiled.

Elevate – Several times a day, elevate your leg ABOVE the level of your heart.  You may use pillows to elevate the leg. Place the pillows long ways starting just below the knee going towards your heel.  If you are doing your exercises to stretch the knee flat, it is ok if a pillow is placed under your knee for limited amounts of time.

Diet:

Eating high quality sources of protein will aid in wound healing and help to prevent muscle loss during the recovery process.  Examples of quality protein:  cottage cheese, yogurt, beans/lentils, salmon, chicken or other lean meats, eggs, and nuts/nut butters.  Eating fruits, vegetables, nuts, and whole grains will help prevent constipation.  Drinking plenty of fluids will keep you well hydrated and help to prevent constipation.  Forte Post Op (Forteelements.com) is an excellent source for the nutritional elements needed to facilitate recovery.  Otherwise protein supplements, Vitamin C, Lysine, Vitamin D and a multivitamin have been shown to facilitate recovery.  

Activity:

Your physical therapist has created an exercise plan to strengthen and retrain your muscles as you get used to using your new joint..  A consistent effort is important. Avoid overdoing it in any single therapy session. Assistive devices (walker, crutches) are mandatory until your strength and balance have returned and you are no longer limping.  You will be scheduled to begin Out Patient physical therapy within a few days following your surgery.  In some cases, a home health nurse and physical therapist may come to your home during the first week following surgery. 

Frequent, short walks are the key to a successful recovery. It is recommended that you stand and move around every 1-2 hours during the waking hours of the day. Increase your activity gradually.  A balance between activity and rest is necessary.

You may have difficulty sleeping at night due to discomfort in the operative extremity.  Getting up and moving can help to alleviate the discomfort.  Problems sleeping is usually not due to a sleep disorder and sleeping medication is usually not appropriate.  More effective pain management should lead to better sleep.  As an alternative, Tylenol PM is a safe sleeping aid.  

Please call Dr. Kimball at 801-373-7350 for any of the following:

*There is an answering service available 24/7, 365 days a year.  A medical team member will return your call.

• Pain that gets worse or cannot be controlled with prescribed medications.
• Problems with your incision – Unusual bleeding, new drainage, blood, pus, foul odor, or separation of the incision edges.
• A fever > 101.5 that doesn’t get better after taking your medication.
• No bowel movement within 7 days.
• Nausea or vomiting and unable to keep food and fluids down.
• Signs of deep vein thrombosis (blood clot) – pain, excessive swelling, warmth or redness in the back of the calf.

Call your Primary Care Physician for any of the following:

• Questions regarding your regular medications such as blood pressure, diabetic, or heart medications.
• Symptoms of a urinary tract infection or difficulty urinating.
• Trouble controlling your blood sugar (if you have diabetes).

RETURN to ER for the following:

• Chest pain
• Difficulty breathing – shortness of breath
• Black or bloody stool
• Vomiting blood
• Signs and symptoms of a stroke

Total Knee Replacement (Total Knee Arthroplasty- TKA): surgery is done to replace the damaged joint with artificial surfaces. Even under the best of circumstances surgery cannot return the joint to its normal state. However, an artificial joint will likely diminish pain and improve functionality and is designed to improve your quality of life. 

Timing of the surgery:

“When should I have my knee replaced?” This is a common question and the answer is patient- specific.  It varies from patient to patient and is based on a number of variables.

• Do it when the symptoms from your knee no longer adequately respond to less aggressive treatments. 
• Do it when the pain sufficiently disrupts your daily living and the worth outweighs the expense, difficulty, and risk necessary to have your knee replaced. 
• Patients often ask if the “x-ray” says I need a knee replacement?  My response is that I don’t treat x-rays but rather “treat people”.  The appearance of an x-ray often doesn’t not correlate with the degree of pain, disability or disruption of your quality of life.  Consider doing the surgery when your quality of life is disrupted to the degree that you are motivated to move forward.  

Sometimes, even in the presence of minimal pain, it is appropriate to do a knee replacement because a deformity is rapidly progressing, or range of motion is deteriorating. This is something we can discuss together so that you can make the best-informed decision. 

With few exceptions, I tell patients that they should have the surgery when they are ready. I generally will not tell patients to do it or when to do it, but rather wait for them to tell me that they want to proceed 

Component selection:

There are several companies that manufacture the hardware used in a Total Knee Replacement.  There are a number of variables to consider:

• Surgeons tend to prefer one or two systems based on their experience and personal preference. 
• Even though systems have similarities, the choice of which system to use is a critical one.
• Systems vary in their ability to accommodate for size differences, alignment challenges, and stability issues.
• It is difficult for a patient to become completely educated with system options, and therefore, there needs to be a high level of trust between the patient and myself. Ultimately, the components chosen are, in my opinion, those best suited for the patient’s situation.
• Some systems are more effective than others in restoring normal “kinematics” of your knee.  Kinematics is a way of measuring how your knee moves, bends, and rotates compared to a normal knee.

Knees are available in two basic designs: Standard or what I call “off-the-shelf” knees and “Patient specific Knees”.

“Off-the-Shelf” knees have been in production for the approximately 40 years of course with some significant improvements over the years.  Examples include such companies as Stryker, Zimmer, J&J, Wright Medical, ODC, Medacta and Biomet to name a few.

How to perform an “off-the-shelf” (OTF) knee: In brief, the surgeon opens of your knee, cuts off the ends of the bones and selects a size (usually 1-6) that seems to fit best.  The implants are usually cemented in place and the incision is closed.  When looking at long-term outcome studies of “off-the-shelf” knees about 75% of patients like their result but about 25% don’t like them even though properly done. OTF knees all have a “generic” shape or design.  The human knee however varies significantly in size, shape and geometry.  When looking at the almost 25% of patients that don’t like their end result some are due to the components being too big, too small or substantially different in design from your native knee.  

Patient Specific Knee:   ConforMIS, a small, Boston base company owns the patents to actually create artificial joints specific to the patient.  The process is quite unique.  A CT scan is obtained including the hip, knee and ankle. From that data a virtual replica of the knee is created from which the implants are designed to replicate not only the size but also the shape of your knee.  Alignment of the components is corrected using computer navigation technology based on the images of the hip and ankle.  The net effect is a component that is specific for you.  It fits and it replicates your anatomy.  The manufacturer is able to produce your knee in 5-6 weeks. In comparison, OTS knees which are manufactured in bulk and the surgeon selects the one that seems to fit the best from the choices available.  

In the past several years I have enjoyed extensive experience with the ConforMIS knee having personally performed approximately 4,000 cases.

The ConforMis knee has been demonstrated to produce improved outcomes compared to OTS knees in the following areas:

1. Less bone is removed at surgery (more conservative)
2. Less bleeding occurs after surgery
3. Less pain occurs after surgery
4. Recovery is faster
5. Range of motion is better
6. The knee kinematics more closely matches a normal knee than any other knee on the market.  As such, there is a higher satisfaction rating by patients after total knee replacement than with OTS knees.

Computer Navigation Technology:                                                                                                        I was one of the first surgeons in the US to routinely employ Computer Navigation in total knee replacement in the operating room.  This enhanced my ability to properly align the total knee.  The technology was expensive and added time to the operative procedure but was an important improvement.  With ConforMis knees, the CT scan is employed to correct alignment using Navigation technology however; it is done in the manufacturing process by creating patient specific cutting jigs along with the patient specific components.  This enables the advantages of Navigation however that portion of the procedure is done prior to going to the Operating room thus reducing cost and time in the OR.

Fixation of implant: 

Implants are fixed to the bone by using either cemented or non-cemented technique. Cemented technique is clearly the “gold standard” and according to most studies it produces the best long-term results. Sometimes non-cemented methods are appropriate. It requires ‘in’ growth of your bone into the implant to assure solid fixation. Although slightly less reliable than cemented technique, it can also produce good results. 

Pain Control Protocol, Medications, and Hospital Stay

Pain Control: 

For several years I have been using what is referred to as a “multimodal” approach to pain management. It recognizes that there are various pain receptor sites in the brain and if we block those sites before we cause pain, the effect is much better than if we cause the pain and then try to ‘catch up’ with medication. Therefore, about an hour before the surgery we administer three different types of oral pain medications. We continue those for several days after the surgery to maintain the “blockade” of the receptor sites in the brain. Studies and experience has proven that this results in far superior pain relief. 

Pre-Operative Medications: 

If there are medications that you have already been taking from home (home medications), we will discuss them at your pre operative appointment.  There may be some that you need to stop taking before surgery. 

There are three basic types of receptor sites in the brain responsible for the transmission of pain. Each receptor type can be blocked with a specific medication. It is known that if we block the receptor site before the pain stimulus occurs, the result of reduced pain is far superior to that which occurs if the blockade is not started until after the pain stimulus happens. Again, approximately one hour prior to surgery, three separate oral medications are administered. 

• A narcotic (usually a small dose of a long acting morphine derivative)
• Acetaminophen (Tylenol)
• A Cox 2 analgesic (usually Celebrex)

All three of these medications are continued in relatively low doses throughout the hospital stay and for the first week or two after hospital discharge in order to keep the receptor sites constantly blocked. 

Anesthesia at time of Surgery: 

I prefer, and almost require, regional anesthesia instead of general anesthesia, for total and partial knee replacement. Regional anesthesia means a spinal anesthetic combined with gentle sedation and a long acting local anesthetic injected in the tissues around the knee at the time of surgery.

This is superior in many ways—

• You will feel better and not as “drugged” after the surgery. 
• You will have less difficulty with nausea following the surgery. 
• You will have a much lower risk of blood clots and pulmonary embolism.
• It is reliable and safer than a general anesthetic. 

What is a spinal anesthetic? 

This is an injection of a short acting local anesthetic medication into the spinal fluid in your low back region. It causes numbness and weakness in the legs that can last for 4-6 hours. This is not to be confused with an epidural anesthetic where the numbing medication is placed adjacent to the spinal sack rather than in the spinal sack. In my experience, epidural anesthesia is less reliable.  

Intra-Operative Medications:

The anesthesiologist primarily controls medications administered during the course of the surgery. They include the anesthetic agents that are part of the spinal anesthetic, as well as muscle relaxers and tranquilizing medications. Unlike general anesthetic, you are not completely asleep, however, drugs are often administered such that you do not remember any of the details of the experience since you are generally not completely asleep as occurs during a general anesthetic. 

Additionally, antibiotic medication is provided to help reduce the risk of infection as well as any other medications that may be useful considering your general medication condition and anesthetic needs. 

Nerve Block:

In most cases the anesthesiologist will administer a nerve block (injection) adjacent to the nerves in the upper thigh.  This provides excellent pain control and can sometimes last up to 3 or 4 days thus dramatically reducing the need for narcotics (pain pills).

Post-Operative Medications:

Immediately after surgery medications are given to help you wake up and recover. Intravenous antibiotics will be continued for 24 hours following surgery. Drugs are available to control nausea, provide pain relief and muscle relaxation. Most, if not all, of your “home medications” will probably be continued after surgery. If you take drugs that impact bleeding, they may be modified or temporarily halted. Anticoagulation therapy will be applied as described below in the “Blood Clot/Anticoagulation section on the following page. As part of the “multimodal” approach to pain control, I use a peri-articular long lasting local anesthetic, as well as a continued blockage of the receptor sites responsible for pain sensation as previously described (see Pre-Operative Medications- on previous page).  I additionally employ an adductor canal nerve block with a long acting agent that can give pain relief for up to 3 days.  

Medications at Time of Discharge:

When you are ready to go home you will most likely continue with any medications you were taking before you came to the hospital for this surgery. This will be discussed upon discharge.

You will also be given RX for the following:

1. Anticoagulation
2. Low dose long-acting analgesics (pain relief medication- usually for 7 to 10 days)
3. Short acting analgesics to be taken as needed according to a prescribed schedule
4. Anti-nausea medication if needed
5. Muscle relaxation medication if needed
6. Anti-inflammatory medication

Where do I go after hospital discharge?

Most of my total knee patients are discharged from the hospital on the day of surgery. This is “outpatient surgery”.  In some cases you may be treated as a “23 hour stay” and spend the night before going home but still considered an “out-patient”.  Home Health Physical Therapy is employed to facilitate your recovery during the first 1-2 weeks after surgery An attentive spouse or family member is usually sufficient for discharge to home.

Rehab Centers:  Rehabilitation Centers (also called Skilled Nursing Facilities) although popular in past years now are now rarely used.  In addition to exposure to other diseases, studies have shown a substantially increased risk of infection, blood clot, hospital readmission and cost associated with going to SNF’s.  It is generally better and safer to go home.  Hospitals are for sick people and, unfortunately, the longer you stay in a hospital; the more likely it is that you are going to get sick in my experience.  

When you go home, a home health physical therapist will come to your home usually 3 times per week for 1-2 weeks and help continue the therapy program you started in the hospital. Not all home physical therapists are the same. We can advise you regarding those with whom we have good experience. 

Once you are sufficiently mobile, it may be appropriate to continue your rehabilitation at a local outpatient physical therapy unit or a local gym. These decisions are dictated to a large degree based on your progress, your level of independence and your motivation and proximity of services in your community.  I will help you select a physical therapist with whom we have good experience.  

Blood loss issues: 

I have not encountered the need for blood replacement or transfusion following knee replacement in at least my last 25 years of practice.  Thus it is NOT my practice to have you donate your own blood in advance, nor expect to receive a transfusion as a result of this surgery.  

Blood Clot (DVT- deep vein thrombosis) Prophylaxis/ Anticoagulation: 

DVT describes the condition when blood clots within a vein, thus obstructing the vein. When the clotted 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. A pulmonary embolism can be fatal. A number of things are done both in the hospital and after hospital discharge to minimize the risk of this serious complication. Unfortunately there is no assurance that these treatments will always work. Depending on your history and contributing risk factors we my employ “baby aspirin” or a more aggressive form of “blood thinning” after your surgery in an attempt to reduce the risk of such a complication.  

In Hospital methods to reduce blood clots:

Treatments done both in and out of the hospital include mechanical measures as well as medicinal measures.

Mechanical Measures:

Some of the following measures MAY be used to attempt to reduce the risk of developing a blood clot:

• Active leg exercises and early return to function. Nothing works better than active muscle contractions in encouraging good circulation and reducing the risk of clot.
• Compression of the veins in the legs to minimize pooling of stagnant blood that may lead to clot formation.
• Use of elastic stockings of other devices to compress leg veins.
• Use of elastic wraps or similar devices 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.

Medicinal Measures:

Depending on your specific “risk” factors, some of the following measures may be used in attempting to reduce the risk of a blood clot during and following your procedure:

• Use of blood thinning medication

• Coumadin

• Xarelto

• Eliquis

• Heparin or Lovenox or similar medication

• Baby Aspirin

My Approach to DVT/Pulmonary Embolism Prophylaxis: I prefer to maximize mechanical and medical measures. This means:

• • Compression devices on foot/calf.
  • Early range of motion and out of bed walking after surgery as soon as possible.
  • Use of oral anticoagulant medication is started on the day following surgery.
  • Continued oral anticoagulants 15-30 days following surgery. 

• Unfortunately sometimes we do everything we can and we still experience DVT and Pulmonary Embolism! If that does occur, we attempt to recognize it early and treat it aggressively.

Infection Concerns:

 A post-operative infection can be a significant and major complication. It may lead to complete failure of the surgery. A number of things are done to minimize this risk, although the risk can never be completely eliminated. 

My Approach to preventing infection: 

• Delay surgery if there appears to be a source of acute or chronic infection anywhere in your body. 
• Start intravenous antibiotics approximately 1 hour prior to the start of surgery. 
• Continue antibiotics 24 hours after the start of surgery. These will be intravenous if you are in the hospital overnight or intravenous and oral medication if you go home the day of surgery.
• Employ strict sterile techniques in the operating room to prepare the operative site and minimize risk of contamination.
• ConforMis technology employs disposable single use instruments rather than instruments that are used over and over by other patients and surgeons.  There is evidence that this method further reduces the risk of infection.
• Use surgical techniques that minimize the duration of the surgery. Evidence shows that the longer the operation, the higher the infection rate. 
• Monitor patient and surgical wound post operatively to identify and treat early signs of infection.
• Sometimes infection occurs even though everything possible to prevent it was done. Signs of infection should be carefully monitored.  If any signs of infection are found, the infection will be treated aggressively. 

Physical Therapy

Before Surgery: 

Physical therapy and exercise therapy when performed prior to surgery has some limited value. Unfortunately most patients anticipating surgery are in pain, and aggressive exercise often only makes the pain worse. Efforts to improve range of motion prior to surgery are not often effective. Resistive exercises to improve strength are encouraged. Recent studies demonstrate that efforts at physical therapy PRIOR to total knee replacement REDUCE the need for physical therapy after the surgery and improve outcomes.

In Hospital: 

Physical therapy and rehabilitation starts on the day of surgery. I prefer that you get out of bed and walking on the afternoon following surgery. I start active and passive range of motion exercises on the day of surgery and continue through the hospital stay and at home.  CPM, which is a Continuous Passive Motion machine has been used in the past to facilitate range of motion.  Recent studies question its’ value.  I do not routinely use CPM but there is room for discussion regarding this issue.  

After Discharge from the Hospital: 

Home physical therapy is arranged to assist you for the first week or two following hospital discharge. It consists primarily of doing much of the same exercises that you started in the hospital. Your specific need for these services will vary with your own difficulties and motivation. As soon as you are able to successfully continue on your own or in an outpatient facility home physical therapy can be discontinued. 

Outpatient therapy is sometimes needed as an adjunct to home physical therapy. This involves going to a local facility and receiving instruction and assistance in gaining range of motion, strength and endurance. We can assist you in selecting a physical therapist with expertise in total knee rehabilitation. 

Long-Term Issues

Why do some total knees fail?

• Implant design: Some systems seem to wear better than others.

• Surgical Technique: If your surgeon puts in the knee in less than ideal alignment it is more likely to fail early. 

• Postoperative rehabilitation and compliance: As the patient, you play an important role in the immediate and long-term success of your surgery.  Knee surgery is harder to recover from than hip surgery. You must be ready to work very hard post-operatively, or you will likely not be happy with your result. 

What about infection?

It is known that patients with joint replacements who are having invasive procedures performed or who have other infections are at increased risk of the infection spreading to their prosthetic joint. Antibiotic prophylaxis may be considered for those patients who are at risk. Most recent recommendations are that antibiotics be employed on the day of the procedure for such things as dental work and other more invasive procedures. This should be done for at least the first two years following implantation of your new joint. Some believe that it should be done indefinitely.  I will discuss with you the best approach for your particular situation. 

Wear and implant Failure: 

How long will a total knee last?

There are a number of factors that contribute to the answer. 

• Some knee systems have better long-term experience than others. 
• Many off the shelf total knees done, 20 years ago using technology that we no longer use, have demonstrated survivals in the 90% range at 20 years.  Based on current science we believe the technology we are currently using will exceed the results obtained in the past.
• To assure the longest wear it is important that the device be properly aligned and that your use is reasonable and appropriate. 
• I am often asked if it is permissible to run, ski, jump, etc. on a replaced knee. The answer is not known. There are no good studies addressing the impact of high-energy sports on the survival of knee replacements. Most patients are happy to have a knee that doesn’t hurt and works well for normal daily activities. One company has recently started marketing an “ all terrain” knee. The implication, though not stated, is that somehow this knee will better handle aggressive activity. Some also market a “sports total knee”. I am sorry to admit that there is NO DATA to support these claims. These statements, in my opinion, are marketing claims and wishful thinking. 

The Most Common Reasons why total knees fail and require revision: 

• Infection

• Loosening

• Instability

• Patellofemoral complications

• Polyethylene wear

Minimally Invasive Total Knee Replacement: 

Recently there have been attempts to do this operation through a smaller incision. Many surgeons use a 10-12 inch incision. My standard incision is approximately 6 inches; however the opening varies with the size of the patient. It is possible to do the surgery through a 3-½ inch incision. Recent studies however, have shown there is a high complication rate, higher incidence of poor component alignment, and no significant advantage to the patient. Some still advocate this approach. However, experience has taught that I can produce a more reliable result through an approximate 6-inch incision. This is a decision I believe should be left to the surgeon. The fact that your incision is a couple of inches shorter will offer little pleasure if your knee fails prematurely, or does not work as anticipated. 

Partial knee replacement (Unicompartmental knee replacement)

What is a partial knee replacement?

Knee replacements can be classified in several ways. One way is according to the portion of the knee replaced. For example one portion can be replaced (Unicompartmental), or two (bicompartmental) or three (tricompartmental). Therefore a Unicompartmental knee replacement is a resurfacing or replacement of one compartment of the knee. It is just one of the surgical options for the treatment of osteoarthritis of the knee. 

History/ Background: 

The idea of replacing one portion of the knee is not a new concept. It has been studied and performed since the 1970’s. Though it developed at the same time as total knee replacement, the procedure has taken time to gain widespread acceptance in the orthopedic community. This was in part due to early reports of poor results after the procedure. However, further review of these studies shows that those poor results may be attributed to patient selection, the type of artificial component used, and the surgical technique. Identification and correction of pitfalls in the technique, plus the development of better implant designs, have renewed enthusiasm for uni-compartmental replacement in certain selected patients. The addition of computer navigation to precisely place the components has added significantly to this technically demanding operation. 

ConforMis has employed patient specific technology in creating custom partial knee replacements for more than 10 years.  When properly performed for the correct indications it comes closer to producing a “normal feeling knee” than any other procedure designed for the osteoarthritic knee.  This system very accurately “resurfaces” the worn out compartment of the knee and usually is associated with a very rapid recovery.  Patient satisfaction studies comparing total knee to partial knee patients highly favor the partial knee results.

What are the indications for Unicompartmental knee replacement? 

Every person’s case is different so we should discuss what is right for you.  Here are the general indications that I use for patients who undergo uni-compartmental replacement: 

• Pain with weight bearing on one side of the knee (the inside of medial side of the knee)
• X- Ray showing narrowing at predominately one side of the joint. 
• Failure to respond to non-operative care or operative efforts at cartilage treatment (repair, replacement, or regeneration of articular cartilage.)

Relative Contraindications for the Procedure:

• Inflammatory arthritis like rheumatoid arthritis, lupus arthritis, psoriatic arthritis, arthritis inflammatory bowel disease. 

• Severe curvatures of the legs like severe bowleg or knock-knee. Mal-alignment can usually be corrected when total knee replacement is performed, however little if any alignment correction can be obtained when performing partial knee replacement. 

• Obesity: Results of partial knee replacement in the obese is less predictable 

What Can I Do to Recover and Heal Faster?

I am often asked, in anticipation of surgery or major injury recovery, WHAT ELSE CAN I DO?

This is my answer and recommendation:

In anticipation of your surgery there are a number of things you will be asked or even required to do in an attempt to assure the best possible outcome.  There is abundant scientific evidence that the specific focused application of nutritional products can not only better prepare you for your surgery but also enhance your recovery.  Most of us are deficient in many nutritional components that are needed by the body to respond to the stress of surgery and the demands of healing and recovery. The nutriceutical industry is confusing, unregulated and contains products that may or may not contain what is actually on the label.  

I recommend you prepare for your surgery by doing the following:

1. If you are already taking one or several nutriceutical products, stop taking them at least 2 weeks prior to your scheduled surgery.  They may contain items that are unsafe or contribute to excessive bleeding at the time of surgery.
2. Go to the website:  forteelements.com and acquire:
   1. Forté Pre-op  This product is taken daily for 2 weeks prior to surgery.  It contains essential amino acids and other key micronutrients formulated to better prepare your body for the anticipated surgery.
   2. Forté Post-op This product is taken daily for 4 weeks after surgery beginning when you return home from the hospital.  It contains an intense combination of vitamins, minerals, trace elements, probiotics, Omega 3’s and Essential amino acids formulated to support your body’s unique nutritional demands associated with healing and recovery.  This approach has been shown to reduce cost, complication rates and improve outcomes.
3. If these products are not available then, at a minimum maximize your protein intake before and after surgery, increase vitamin C and Vitamin D support.  
4. If, because of timing issues you do not have time to take the “pre-op” prior to surgery, then only acquire the Post-op product.
5. These products are recommended by your physician and qualify as a medical expense for tax purposes. Nutriceutical products are not paid for by health insurance plans but can be paid for or reimbursed by HSA accounts.  
6. My efforts and preparation combined with your best efforts and preparation represents the best we can do as a team to contribute to the best possible recovery from your surgery or injury.  

Kirt Kimball MD