Knee Replacement: Pre-operative Steps, Medical Evaluation, and Physical Preparation

What is the procedure before knee replacement?

The procedure before knee replacement surgery is a comprehensive, multi-stage process designed to thoroughly assess a patient's suitability for surgery, optimize their health, educate them on the upcoming procedure and recovery, and physically prepare them for the best possible outcome.

Initial Consultation and Diagnosis

The journey toward knee replacement typically begins with persistent knee pain and functional limitations that have not responded to conservative treatments.

• Symptom Assessment: The orthopedic surgeon will conduct a detailed interview, asking about the onset, nature, severity, and aggravating/alleviating factors of your knee pain, as well as its impact on daily activities.
• Physical Examination: A thorough physical assessment will evaluate your knee's range of motion, stability, strength, alignment, and the presence of swelling or tenderness. The surgeon will observe your gait and how you perform functional movements.
• Imaging Studies: X-rays are standard to visualize the joint space, bone spurs, and overall bone health, confirming the extent of arthritis (e.g., osteoarthritis, rheumatoid arthritis) and joint degeneration. In some cases, an MRI or CT scan may be used for more detailed soft tissue or bone assessment.
• Review of Conservative Treatments: The surgeon will review previous non-surgical interventions, such as physical therapy, medications (NSAIDs, corticosteroids), injections (corticosteroids, hyaluronic acid), and lifestyle modifications, to confirm that these options have been exhausted or are no longer effective.
• Diagnosis Confirmation: Based on the clinical findings and imaging, a definitive diagnosis is made, and the necessity and appropriateness of total knee arthroplasty (TKA) are determined.

Medical Evaluation and Optimization

Once knee replacement is deemed necessary, a comprehensive medical evaluation ensures you are healthy enough to undergo major surgery and anesthesia.

• General Medical History and Physical: Your primary care physician or an internist will conduct a thorough medical assessment, including a review of all existing medical conditions (e.g., heart disease, diabetes, lung conditions), past surgeries, and allergies.
• Diagnostic Tests: This typically includes blood tests (complete blood count, metabolic panel, coagulation studies), urinalysis, and an electrocardiogram (ECG) to assess heart function. Further tests, such as a chest X-ray or echocardiogram, may be ordered based on your medical history.
• Medication Review: All current medications, including over-the-counter drugs, supplements, and herbal remedies, must be disclosed. Some medications, particularly blood thinners, will need to be adjusted or temporarily stopped before surgery.
• Specialist Clearances: Patients with significant pre-existing conditions (e.g., cardiac issues, severe lung disease, uncontrolled diabetes) may require clearance from specialists like a cardiologist, pulmonologist, or endocrinologist to ensure their condition is optimized for surgery.
• Dental Evaluation: A dental check-up is often recommended to rule out any active infections, as oral bacteria can potentially spread to the new joint, leading to a severe infection. Any necessary dental work should be completed well in advance of surgery.
• Nutritional Assessment: Ensuring adequate nutrition is important for healing. If there are concerns about malnutrition or obesity, these may be addressed prior to surgery to improve outcomes.

Pre-Operative Education and Planning

Education is a cornerstone of successful knee replacement, empowering patients with knowledge and reducing anxiety.

• Surgical Overview: The surgical team will explain the procedure in detail, including the type of implant, the incision, and what to expect immediately after surgery.
• Risk and Benefit Discussion: Potential risks, such as infection, blood clots, nerve damage, and implant loosening, are thoroughly discussed, alongside the expected benefits of pain relief and improved function.
• Pain Management Plan: A strategy for managing post-operative pain will be outlined, often involving a multimodal approach with different types of pain medications.
• Rehabilitation Expectations: The importance of post-operative physical therapy is emphasized, with a general outline of the rehabilitation timeline and goals.
• Discharge Planning: Discussions will cover where you will go after discharge (home, rehabilitation facility), what assistance you will need, and how to prepare your home environment.
• Anesthesia Consultation: You will meet with an anesthesiologist to discuss anesthesia options (general vs. regional) and address any concerns.

Physical Preparation (Prehabilitation)

"Prehabilitation" refers to exercises and physical preparation undertaken before surgery to improve physical capacity and accelerate post-operative recovery.

• Physical Therapy: A physical therapist may prescribe a tailored exercise program focusing on:
  • Strengthening: Targeting the quadriceps, hamstrings, glutes, and calf muscles to improve muscular support around the knee. Stronger muscles pre-surgery can significantly aid in regaining function post-surgery.
  • Range of Motion (ROM): Working to maintain or improve the knee's flexibility, as a greater pre-operative ROM often correlates with better post-operative ROM.
  • Cardiovascular Fitness: Engaging in low-impact aerobic activities (e.g., cycling, swimming) to improve overall endurance and reduce surgical risks.
  • Gait Training: Practicing walking with assistive devices like crutches or a walker, which will be necessary immediately after surgery.
• Weight Management: If overweight or obese, losing even a small amount of weight can reduce stress on the knee, decrease surgical risks, and improve long-term implant longevity.
• Smoking Cessation: Quitting smoking is strongly advised, as it significantly impairs healing, increases infection risk, and complicates anesthesia.

Logistical and Home Preparation

Practical arrangements are crucial for a smooth recovery period.

• Home Modifications: Preparing your home by removing trip hazards (rugs), arranging frequently used items at an accessible height, installing grab bars in the bathroom, and ensuring a comfortable recovery area.
• Assistive Devices: Obtaining necessary equipment such as a walker, crutches, elevated toilet seat, shower chair, and long-handled reacher prior to surgery.
• Support System: Arranging for family or friends to assist with daily tasks, transportation, and emotional support during the initial recovery phase.
• Administrative Tasks: Completing necessary paperwork, understanding insurance coverage, and planning for time off work.

The Day Before Surgery

As surgery approaches, final preparations are made.

• Fasting Instructions: Adhering strictly to instructions regarding food and drink intake, typically involving fasting for several hours before surgery.
• Medication Adjustments: Following specific instructions on which medications to take or avoid on the day before and morning of surgery.
• Hygiene: You may be asked to shower with a special antiseptic soap to reduce the risk of infection.
• Packing: Preparing a bag with comfortable clothes, toiletries, and any necessary personal items for your hospital stay.

By diligently following these pre-operative procedures, patients significantly enhance their readiness for knee replacement surgery, contributing to a safer procedure, reduced complications, and ultimately, a more effective and quicker recovery.