6 week follow-up total knee
Congratulations! You have made it through the hardest part of recovery from total knee replacement. We knew it would be difficult, but hopefully the preoperative education prepared you well, so that you knew what to expect. This handout will address current symptoms and expectations going forward as well as frequent concerns and questions.
At this point you almost certainly still have pain or discomfort in your knee ALL the time. It should not be severe enough to require opioid medication, but it will still be helped with Tylenol and NSAIDS (anti-inflammatory medication) if you are able to take them. Examples include Mobic, Celebrex, or over the counter medications like Aleve or Ibuprofen. You should continue to ice your knee for 20-30 minutes following your daily exercises and for 20-30 minutes prior to going to sleep.
Speaking of sleep. You probably are having or have had a lot of trouble with sleep. This is an almost universal complaint. Unfortunately there is no cure other than time. Fortunately, there is good news. It will improve! By 3 months after surgery your sleep patterns will be back to normal if not before then. Here are things to try to help now. Sleep aids like Tylenol PM or just Benadryl 50 mg. Reducing inflammation before bed time is also helpful, so take your NSAID (see above) right before bed and ice for 20-30 minutes right before bed. You can also try over the counter 0.4% lidocaine patches on both sides of the incision. Place them 1-2 hours before bed and remove in the morning.
Because of poor sleep, but also because you have been through a big surgery you are also noticing fatigue. You just can’t do as much as you want or go as long in the day without being worn out. This also fully recovers by about 3 months. The best way to work on this is with low impact aerobic exercise. That’s right it is time to start exercising! Walking (but not on a treadmill yet), elliptical trainer, stationary bike, walking in the pool, or swimming are all options. Start slowly and build up. Your goal should be to do at least 30 minutes of aerobic activity without stopping 3-4 times a week by 3 months after surgery. You can hit the treadmill at 6 months. A guide to resistance on elliptical or stationary bike is to increase the resistance when 30 minutes is too easy.
You may be seeing a theme so far. It takes about 3 months to be back to feeling “normal”. You may remember before surgery we said 3 months is when you feel as if you have recovered from surgery. Your knee will not be 100% recovered but it should definitely feel better than before surgery and you will have times in the day that you forget about it. This also means your energy will be back. Your appetite will be back, and your sleep will be back!
Other common concerns are explained by the inflammation in the knee. The body uses inflammation to heal. That’s great, but inflammation causes symptoms we don’t like. PAIN, SWELLING, HEAT, and REDNESS are normal and I’m sure you have all of them. Your knee and to some extent your leg will be swollen for months. Your knee will feel warm or even hot until your incision is the same color as your skin. Remember that the skin incision is just the tip of the ice berg of the surgery, so if it looks inflamed then the inside of the knee is definitely inflamed. It’s at least a year until that is totally gone.
Your range of motion has not yet peaked and you should continue to working on bending your knee daily for the next 6 weeks. Your final flexion number depends a bit on how well you could bend before surgery. In general our goal for you is 120 degrees of bend. You need about 105 degrees to perform normal daily function. If your knee is not fully straight you should also work on this. With your leg out straight rest your heel on something and push your knee gently out straight for several minutes. Do this 3 times a day. Walking backwards short distances also helps straighten the knee. Be patient! If you are diligent you will straighten your knee 2-3 degrees/month. If you are having trouble with your range of motion or still using a walking aid we may recommend more physical therapy. It’s not time to lift weights yet. Range of motion exercises and aerobic exercise only for the next 6 weeks. Strengthening starts at 3 months after surgery.
You have also noticed your knee POPS or CLICKS. This is normal. The knee replacement is hard metal and plastic so it makes noise. This will not go away, but you will be less aware of it over time. The outside of your knee is NUMB. This is also normal. Over the first year much of the feeling comes back. If you have tried to KNEEL you have noticed pain. It is ok to kneel, but most knee replacement patients find it very uncomfortable. If kneeling is important you can train your knee 6 months after surgery with the following protocol:
Week 1 - kneel 10 minutes a day on a couch
Week 2 - kneel 10 minutes a day on a couch cushion on the floor
Week 3 – kneel 10 minutes a day on a thin pillow or a thick carpet
Week 4 – kneel 10 minutes a day on a thin carpet or rug
Week 5 – kneel 10 minutes a day on the floor or ground outside.
At this point, you should be back on all of your pre surgery medications. The only “new” medications that you might still want to take are Tylenol and a NSAID (anti-inflammatory) for discomfort. Additionally you must take an antibiotic before any dental procedure including routine cleaning for the rest of your life. If you do not have a penicillin allergy you take 2000mg of amoxicillin 1 hour before. If you have a penicillin allergy you take 600 mg of Clindamycin 1 hour before. Our office or your dentist can provide you this prescription. For urologic procedures (bladder, urethra, ureter, kidney) you should take 500mg of ciprofloxacin 1 hour before. You do not need antibiotics before a routine screening colonoscopy, but is a procedure or biopsy is to be performed you should discuss a pre-procedure antibiotic with your gastroenterologist. You do not need antibiotics before routine gynecologic exam, manicure, pedicure, or injection.
And finally, a review of what to expect going forward. The next 6 weeks you will get back to feeling normal. Your stamina and endurance will improve. As mentioned you should slowly ramp up your aerobic exercise and continue to work on range of motion. At 3 months after surgery you can be more intentional about strength training. More hills, more stairs, biking on the road, and lifting weights. Use common sense and gradually build up. When lifting weights you should choose a lighter weight that you can lift 20-25 times. Over the next several months you will notice that you have less and less pain with walking, but you will still feel stiff and uncomfortable with prolonged sitting. This is normal and does get better but it can be as long as 12-18 months of gradual improvement. We will continue to follow up with you periodically depending on your progress. Because your joint replacement can wear out, we will recommend periodic x-rays to assess wear. These are typically spaced 2-5 years apart if you are having no problems. Stay diligent with your exercises as outlined, continue to be patient with your recovery. Once fully recovered you should be satisfied with your new knee for many years to come.
