Your orthopedic surgeon has examined your painful, stiff and swollen knee. You have answered questions regarding the pain you feel-the exact location, when it started, how long it lasts, whether it comes and goes, what activity causes it to hurt most-and responded to inquiries regarding past injuries to your knee, pain in other joints, family history of joint pain and whether or not any physician has ever given you a diagnosis of arthritis. Your physician suspects osteoarthritis, but to be sure, he/she will order a number of tests to confirm the diagnosis and to rule out any other possible causes of your pain.
X-ray and MRI
The first test you can expect is an x-ray of your knee which is taken from various angles to provide an accurate visualization of the damage in your joint. If the physician suspects damage to ligaments or a meniscus, you may also undergo an MRI (Magnetic Resonance Imaging).
Inasmuch as there are several diseases that can cause arthritis or arthritis-like symptoms, your physician will order particular blood tests to detect and identify the presence of any disease other than osteoarthritis that may be the source of your pain. For example, patients with rheumatoid arthritis, as opposed to osteoarthritis, will have elevated levels of what is referred to as rheumatoid factor (caused by specific antibodies in the synovium or cell lining of flexible joints). Another blood test, called an erythrocyte sedimentation rate (ESR or “sed rate”) indicates an inflammatory arthritis or other related condition-such as rheumatoid arthritis or systemic lupus erythematosus-if the level is above a certain range. A test that measures the amount of uric acid in the blood may indicate or rule out gout as the cause of your joint pain. If your physician suspects a rheumatologic illness based on your health history, age and physical findings, there are a number of other blood tests that may be ordered to narrow the field.
Tests on Synovial Fluid
If the diagnosis is uncertain or your physician suspects an infection, a sample of synovial fluid may be withdrawn from your knee joint and sent for testing to confirm or rule out osteoarthritis. Examples of possible results are:
Cartilage cells in the fluid which are indicative of osteoarthritis.
A high white blood cell count which is a sign of an infection.
A high uric acid level which is an indication of gout.
There are a number of other factors in the synovial fluid that may be tested if the physician needs further elaboration.
The results are in. Your orthopaedic surgeon informs you that your diagnosis is indeed osteoarthritis. If you think you are alone in your misery, here are a few facts you might like to know:
Osteoarthritis is the most prevalent form of arthritis, one of the most common diseases affecting humans and a common cause of disability. In 1998, it was estimated that more than 20 million Americans had symptomatic osteoarthritis (OA). As our population ages, the incidence of OA is expected to increase dramatically over the next 20 years.
OA is the second most common reason men over 50 claim work disability.
OA is a major cause of disability in persons over 65.
OA is often present, although asymptomatic, as early as the second or third decade of life.
By age 40, nearly everyone has some osteoarthritic changes in weight-bearing joints such as hip and knee.
At age 75, it is a truly amazing human that does not have arthritic changes in at least one joint.
According to radiologic studies (x-rays), OA of the knees is more common in women; OA of the hips is more common in men.
Now that your diagnosis is confirmed, it is time to discuss your options. Your orthopaedic surgeon suggests a knee replacement and tells you about the several types of replacements that are currently considered state of the art. He/she explains the difference between a partial and a total knee replacement-including the new computer-guided minimally invasive approach used with total knee replacements-and the indications for each. In the end, your surgeon’s opinion is that you would benefit by having a total knee replacement.
Questions to Ask
Before you agree to consider your surgeon’s recommendation, make certain you ask the following questions:
What are the details of the procedure that you are recommending?
What is your experience with this procedure? How many have you done?
Are you board certified?
Why do you feel I need this operation now?
If I don’t have this surgery, what are the other options available to me?
How do you anticipate this surgery will improve my current situation?
Will the surgery be performed under local or general anesthesia?
What are the risks involved in this surgery?
What can I expect in the recovery process?
You may also want to get a second opinion as well as check to see that your health care company covers this procedure.
You are now ready to go to the next step which is planning for your surgery, but until you know exactly what to expect both pre-operatively and post-operatively, it is hard to know what adjustments you will have to make in your life.
You can anticipate further tests to ensure that you are healthy enough to withstand the surgery and the anesthesia and to make a full recovery. These may include (but not be limited to) a complete blood count, including electrolytes; tests to measure blood clotting time (APTT & PT); chest x-ray; electrocardiogram; and a blood test to detect your blood type and other blood type-related factors should a transfusion be required.
It is also commonplace to meet your anesthesiologist in advance of your surgery to discuss any past experiences with anesthesia that you may have had. The anesthesiologist will ask you if you have allergies to food or drugs and he/she will want to know if you have any false teeth, braces, bridge work or capped or bonded teeth that may require special consideration during the administration of general anesthesia. Finally, the anesthesiologist should be willing to answer any questions that you might have with respect to his/her part of the surgery such as the type of anesthesia (local or general) he recommends, how long you can expect to be under anesthesia, how long it will take you to fully awaken following the surgery and so on.
Either the orthopedic surgeon or the anesthesiologist (or both) should review any medications you currently take and advise you as to which ones you can continue (even on the day of surgery itself) and which ones you should discontinue several days prior to surgery, such as Warfarin or aspirin which purposefully lengthen the time it takes for blood to clot.
Ordinarily, patients are examined and given a pre-op work-up one or more days prior to surgery with the actual surgery performed on the day of admittance. Sometimes however, the patient is asked to come to the hospital the night before surgery.
Discontinue any medication as directed by your physician
You may be asked to scrub the operative area several times with a special antibacterial preparation on the day before or day of the surgery.
You will be told not to eat or drink anything after midnight on the day of your surgery.
You may be given an injection to help you relax just prior to surgery and if you are to have general anesthesia, the injection may include a medication designed to aid in the drying of secretions, the point being to reduce the amount of saliva produced while you are under anesthesia.
An intravenous may be started before you leave for the operating room or after you arrive there.
You will be taken by stretcher or wheel chair to the operating room.
Operating Room and Recovery Room
The surgery itself will take several hours and will vary from person to person based on the degree of damage that exists and the ease with which the implant is inserted. You can expect to have an incision about 3-4 in. long. If you have had general anesthesia, it will take some time (an hour or so) before you awaken. In some hospitals you will be sent to the Recovery Room and monitored until you are fully awake, then when your vital signs are stable and your surgical site meets a particular standard, you will be returned to your room. In other surgical centers and especially if you have had local anesthesia, you may be monitored in the operating area before being sent back to your room. You can expect to have an intravenous, a bandaged knee, and some discomfort, especially as the anesthesia wears off.
Pain Management – Most hospitals today allow individuals to manage their own pain with a medication pump that delivers a pain killer intravenously as needed. When your intravenous is removed, you may receive medication for pain either by intramuscular injection or by mouth. The quantity, frequency of administration, length of time needed, method of delivery and kind of medication varies from person to person.
Blood Clot Prevention
Compression stockings – One of the primary risks in knee surgery is the formation of blood clots in the lower leg veins. These clots, once formed, can migrate to the heart, lungs or brain resulting in heart attacks, cessation of breathing or stroke, all of which can be catastrophic. The best way to manage clots is to prevent their formation in the first place; therefore, a great deal of post-operative therapy involves attention to this issue. Immediately after surgery, you can expect to have electrically operated compression stockings applied. These stockings prevent blood from pooling in the lower extremities-a common factor in the formation of clots-by helping to reduce swelling and by assisting your circulation. You can expect to wear them continuously for the first few days following surgery and then for as long as six weeks thereafter, especially while you are sleeping, sitting or prone.
Blood thinners – You can expect to take a blood thinning medication by subcutaneous injection for from 7-10 days. When you are discharged, you or a family member will be taught how to administer this medication. If you follow up your hospitalization in a rehabilitation center, the medication will be administered by hospital staff or if at home, it can be administered by a home health care representative.
Ambulation and exercise – Hospital staff will assist you in getting out of bed as early as the day following surgery, but it is important to walk with the assistance of a walker or crutches at every opportunity because exercise and ambulation increase the blood flow to the surgical area which in turn helps to prevent clots and aids the healing process. Plan on using some walking aid-crutches, a cane or a walker-for 36 weeks post-surgery.
Staples/Sutures:These are usually removed about 2 weeks following surgery.
Driving and Employment: It is recommended that patients abstain from driving until they no longer need to walk with crutches, a cane or walker. Plan to take a leave of absence from work for 3-6 weeks. Of course, how long you need to be away from work will depend on the particular requirements of your job.
Physical Therapy Individuals vary in their need for physical therapy, but despite differences you can be sure that some physical therapy will be ordered for you. The length of time that you will need to continue therapy will depend on your healing time, how well you can ambulate independently and your recovery in general. There are three primary types of rehabilitation services used: home health care, rehabilitation hospital, and out-patient rehabilitation.
Warning Signs of Blood Clots It is important to know the warning signs of a blood clot in the event that one begins to form despite all your efforts at prevention. Take immediate action if you have (1) increased pain or tenderness in your calf or the inside of your thigh (2) increased swelling in your calf, ankle or foot (3) sudden shortness of breath (4) sudden onset of chest pain (5) localized chest pain with coughing (6) any changes in vision.
In spite of the warning above, total knee replacements have a better than 90% success rate and are far more effective at restoring mobility and relieving pain in patients than non-surgical treatment. If you are contemplating a total knee replacement, approach the experience with a positive attitude, become an informed consumer, have confidence in your surgeon’s ability and look forward to an improved quality of life.
The information in the article is not intended to substitute for the medical expertise and advice of your health care provider. We encourage you to discuss any decisions about treatment or care an appropriate health care provider.