Introduction – Total Knee Replacement (TKR)
A total knee replacement is a big undertaking for any patient. The main indication is wear and tear arthritis (osteoarthritis) of the knee joint. The smooth joint surfaces have been worn away (see picture 1)causing pain, swelling, stiffness, deformity and loss of function. Patients should have exhausted non operative treatment options for their arthritic knee, before embarking on a TKR. The operation usually involves a general anaesthetic and takes about an hour and a half to do. It’s performed through a midline skin incision (cut) on the front of the knee. (see picture 2) The joint capsule is opened by cutting around the knee cap on the inside. The damaged ends of the joint are exposed and then cut away onto which measured implants (see picture 3), made of an orthopaedic metal alloy, are cemented into place, using special bone cement. A specialised piece of high density plastic, called polyethylene sits between the metal implants to create the new smooth joint surface. Often the knee cap is replaced as well. The soft tissues and ligaments are balanced, so the knee is stable as it moves from fully straight through to fully bent.
Operating on the knee causes a fair amount of internal bleeding and in the first few weeks after surgery – post operative surgical pain, swelling and bruising is inevitable. Despite my best efforts to prepare my patients for those first few weeks it is always a challenging time. Post-operative rehabilitation is a careful balance between rest, elevation and regular, with early range of movement, stretching, weight bearing and strengthening work. This is all guided with the help of the physiotherapists. Most patients stay 2-3 days in the hospital.
Follow up after TKR
After discharge from hospital I like to see my patients at the 6 week mark to check they are getting over this difficult early post-operative spell and progressing with their rehabilitation. I measure range of movement on the couch and get x-rays to check the implants are in a good position.
Occasionally if patients are not getting the range of movement back as quickly as we like I may offer a manipulation under anaesthetic (MUA). In my experience it is always good to do this early in the post-operative phase at about the 6-12 week post op range.
What is an MUA?
This involves coming back into hospital for a daycase or overnight stay and giving the knee a controlled bend either under a general (asleep) or spinal (numb legs from waist down) anaesthetic. The knee is very carefully bent over a period of 10 minutes or so to release some of the scar tissue that has built up inside. Afterwards when we have achieved the desired amount of movement the patients leg is put onto a (continuous passive motion machine (CPM) to help maintain that range for the next few hours. (See video 1) Then it is back to the physios and more hard work getting the exercises going again.
Video 1 – CPM machine in action: https://www.youtube.com/watch?v=8z-wjHFiBq0
I’m incredibly grateful to my recent patient, below gives an honest and realistic account of his experiences of a total knee replacement and a manipulation under anaesthetic.
If you have knee pain and want to see Mr. Davies privately please contact Debbie Rollason directly on email@example.com or 07305097137
Testimonial January 2019
“I’m a 62 year old man who has worked in the building industry all my life and played football in a Saturday and Sunday league until I was about 34years old. I currently work as a maintenance fitter.
I had right total knee replacement surgery performed by Mr Nev Davies at Circle Hospital, Reading on 24/9/18 (via the NHS). After seeing my x-rays and prior to this surgery Mr Davies recommended I seek a second opinion from Mr Sean O’Leary. For speed and due to the amount of pain I was in I chose to pay privately to see Mr O’Leary.
Both Mr Davies secretaries, NHS and private where very helpful with all the arrangements for these appointments and the administration prior to surgery.
Mr Davies and Mr O’Leary appeared really experienced in this type of surgery, their bedside manner and knowledge was exceptional and both concurred with the right knee replacement diagnosis and further diagnosis of left knee and hip surgery. They also fully explained the procedures to me, the pain issues I would experience and life after surgery. I felt they both naturally made time to fully talk through this with me and answered all questions.
Prior to the surgery I attended a class at Circle Hospital where an experienced Physiotherapist advised a class of patients what to expect she emphasised the issue around pain and the need for possible extended pain relief, way and beyond returning to work. I really underestimated her advice.
The surgery was straight forward and I stayed in hospital 3 nights, I really wasn’t confident and pain controlled to come out after 2 nights. On discharge I was given a pain relief programme and a physio appointment.
So my recovery began but I never ever expected to be in the pain I was in, I could not manage the pain, I couldn’t sleep, I couldn’t eat, I couldn’t walk without extreme pain and I mean nagging, aching, constant, pain. I proactively did my physio and icing at least 4/5 times per day but could not progress whatsoever. The pain was impeding my recovery. My GP changed my pain relief medication and I made some really small progress. Due to this limited progress, my physio liaised with Mr Davies and it was agreed I attend Circle Hospital Physio every weekday for four weeks, I did this and I was placed on an automatic knee bending machine, called a CPM which gave me great results at the time but once I was off it I returned to the normal stiffness and pain.
I saw Mr Davies on 7/11, and reported I felt the movement in my knee was not right and pain was impeding my recovery. I knew my own body and I really felt there was something not right with my right knee. It appeared on examination that my knee had locked and it needed a manipulation procedure. On 26/11 Mr Davies did the manipulation procedure under epidural and I came home the same day. He assured me I was just unlucky and this manipulation procedure was nothing I had attributed to.
It was only after this manipulation procedure that my progress increased. I was still in severe pain, but from the second procedure, it was so sore and swollen, again my GP changed my pain regime and things then started to improve.
I purchased a static bike stand from Halfords for £50 to immobilise my own pedal cycle and set about cycling 3/4 times a day in the back garden, as well as the exercise programs I had been given by my Physio. Gradually the knee got better and better, the pain got less and less and manageable.
I also paid for a package of 6 hydro therapy treatments at Circle Hospital, which Hannah has been instructing me on, they are tremendous, I have one a week and the movement and release I’ve got from these are excellent. Well worth the money, but don’t under estimate how exhausted you will be after them. £300 for 6.
As it stands today 8 wks after the manipulation procedure and 16 weeks after the replacement I am making really good progress. I am still on pain killers during the day but have stopped taking the morphine based ones in the morning and night now. I feel human again, and am walking and driving ok and should be returning to a phased introduction back to work shortly.
When you are discharged from hospital I recommend that you get a family member to take your copy of your discharge papers from hospital to your GP for scanning into your file, otherwise your GP will not prescribe any additional pain relief drugs, I was too poorly to speak or attend my GP at one stage and they required evidence of surgery, and it was a monumental task for my wife getting past our GP Receptionist, with different advice on every visit.
Additionally, NHS funding authorisation for the operation is required by your GP , this is a whole other ball game and requires a firm proactive approach, with constant calls for weekly requests for updates, or pushing the progress. You really need to be on top of this. However, the funding officer at Circle Hospital, offered me excellent advice and I had frequent e mail updates.
Phew what a journey, I never ever expected this pain and swelling and I recommend if your considering this surgery, you should seriously think about appropriate pain relief which also assists you sleeping at night, resting in the day, ice is key to the swelling, using a bike is the best exercise and it gave me immediate movement in the knee, and if affordable consider hydro therapy. But the operation is so worth it, the nagging bone on bone constant nagging pain has gone. With a bit of bad luck, unfortunately, investment in all the above post op physio treatment I’ve got a great new working knee. All in all Mr Davies particularly , and his team have done a brilliant job. Thank you. see you next year for my left knee.”
Nev Davies FRCS (Tr.&Orth.)
Specialist Knee Surgeon and Consultant in Trauma & Orthopaedics
Reading Hip & Knee Unit