Achieving faster recovery and better results after knee replacement

Like any major surgery, knee replacement surgery requires a significant period of recovery and rehabilitation. Greater success and a faster recovery depend heavily on a wide range of initiatives.

An overview of recovery following a knee replacement

Rapid recovery is the return to normal function - as soon as possible - after knee replacement surgery. Patients should expect to be up and walking at about three hours after surgery. They will also be able to climb stairs on the same day or the next morning after their surgery.

Patients usually stay in hospital for a night or two after surgery and I’ll see them again two weeks later. At this point, I’d expect to see a well-heeled scar with a nice range of movement in the knee.

And then by approximately six weeks, they will be able to return to light sporting activities, such as golf, gentle tennis and walking quite long distances.

The holy grail of knee replacement surgery is for patients to have a natural feeling knee and one day forget they’ve had it done... the “forgotten knee”.

What are the major recovery milestones?

The first few weeks post-op

I expect 70% of my patients to be driving at 2 weeks - as soon as the wounds have healed and they feel confident they’d be able to perform an emergency stop.

Once you have achieved good flexibility in the knee, it is important that you let the soft tissues settle without over exercising, as that can lead to excessive swelling and a capsulitis - which in turn will slow down your functional recovery.

Cryotherapy should continue for four weeks after surgery - ideally 4 times a day. Then between 2-4 weeks, the emphasis is normally on returning to “activities of daily living” without over exercise or “building muscles”.

Patients begin to enjoy returning to sports like golf and light tennis at about 6 weeks. Full recovery following a knee replacement takes a variable amount of time - for some this happens within 6 weeks and for others, it can take a year.

A fast recovery is never a guarantee, but Mr Rajaratnam is in the top 1% of UK surgeons for patient quality of life improvement and knee function scores.

Rapid Recovery Programmes after surgery

This protocol is most often used in good orthopaedic units. It is the improvement of many different parameters before, during and after surgery to create the conditions for a smooth, easy, short and longer term recovery.

Recovery starts before surgery - with pre-habilitation

In the weeks prior to surgery, we strongly encourage patients to work with specialist physiotherapists to achieve an improved range of motion within the joint - along with better muscle function.

Ultimately, the stiffer a knee joint is pre-operatively, the harder the rehabilitation is after surgery and the worse the range of motion you achieve at the end of the eventual knee replacement - making recovery harder work for the patient.

If you are carrying excess weight pre-operatively, losing weight prior to your knee replacement makes recovery from surgery easier and safer.

Rapid Recovery Programmes get patients off to the best start

Mobilising a patient - getting them walking within 3 hours of surgery - has an excellent effect on their recovery.

Rapid recovery protocols reduce complications by getting the circulation going, building patient confidence, reducing pain and stiffness, and reducing complications of surgery that can occur due to bed-rest.

The benefits of walking almost immediately after surgery are well documented and mostly relate to reducing complications that result from being sedentary. So, walking reduces the risk of blood clots; ventilates the lungs thereby reducing the number of chest infections, and reduces the likelihood of urinary retention - a fairly common complication of orthopaedic surgery.

A rapid recovery programme, reducing the unnecessary complications of lying in bed in pain post-op, is what begins both a better short and longer term recovery.

Advancing anaesthesia for rapid recovery after knee replacement

The anaesthetist uses a combination of techniques. These can include: a spinal injection to numb the legs, general anaesthetic or deep sedation, a local anaesthetic in the soft tissue of the knee and local anaesthetic nerve blocks so the patient is pain-free, comfortable and confident when walking.

I work with a leading consultant anaesthetist Dr. Barry Phillips, and together we have carefully developed protocols to reduce peri operative pain after knee replacement surgery. We have learned lessons from over 5000 knee replacements we have performed together and continue to adapt and tweak our pain relief protocols to make this difficult journey much easier for the patient.

Sleep & recovery

Perhaps the most frustrating thing for patients is the sleep disturbance they can suffer at night post-surgery - especially if they were a light sleeper beforehand. But most knee replacement patients start sleeping reasonably well by 6 weeks.

We can often help this with sedative medication in the post operative period, but it is exceedingly important not to become dependent on these drugs.

What about running?

If a patient has had a patellofemoral replacement (when only the kneecap is damaged and replaced), where running doesn't have an impact on it, then I don’t worry so much about running on the implant.

In a partial or full knee replacement involving the tibio-femoral surface, running should generally be avoided if the implant is to last many decades. Increased shock loading of an artificial surface generally leads to wear.

Longer term prospects for knee replacement implants

These days most implants are lasting 25 to 30 years - if surgery is done well - so this procedure has come a long way. But you have to look after it and try not to increase the wear.

I tend to tell people they can ski, ramble and play tennis and golf, but when it comes to aerobic activity, I suggest they skew their sports towards swimming and cycling.

Sport such as tennis is usually fine, but I would advise caution about running on the implant for exercise.

The role of physiotherapy in recovery

Physiotherapy is really important, particularly if you want to get your knee replacement back to a high functioning level.

A master physiotherapist will take you through the following goals:

1. Achieve early range of movement in the knee

2. Manage the soft tissue swelling and make sure you don’t overexercise in the early stage - to avoid a capsulitis

3. Reassure and guide you - so you make a faster functional recovery, driving after two-three weeks, and resuming activities of daily living

4. Liaise with your surgical team to optimise your pain relief

5. Encourage icing and cryotherapy

6. Work towards sport specific goals after 6 weeks

7. Gently build your musculature after soft tissue recovery is complete - but this must only be a priority once the knee has fully settled (perhaps after 3 months) as it can cause a capsulitis and pain if made a priority too early.

In summary, when does the ‘new knee’ feel normal?

Unlike hip replacement, where leading surgeons are helping the majority of their patients forget they’ve had the surgery, knee replacement is more complex and harder due to the complexities of the knee. But the vast majority of patients get there.

A motivated patient, under the care of a great knee surgeon, leading an experienced team who follow a Rapid Recovery Programme; and care from a master physiotherapist who is experienced in knee replacement surgery (not just elite sport rehabilitation) will achieve wonderful results in over 95% of cases.

A word from Compare my Care

Mr Sam Rajaratnam is a super-specialist in knee replacement surgery. A core focus of his practice has been improvements in recovery and outcomes after knee replacement surgery - as part of an experienced multi-disciplinary team.

His results - after over 5000 knee replacements - bear out his achievements and have led to among the highest patient reported outcome satisfaction scores, and lowest revision or failure rates recorded on the National Joint Registry. He is Director of Orthopaedics at the Schoen Clinic London.