Pre-Operative Instructions for
Knee Replacement Surgery
WHAT TO DO IN THE MONTHS/WEEKS LEADING UP TO SURGERY
Work on being healthy/optimized before surgery to maximize your chance of a good outcome
Keep your knee mobile and strong as much as you can without causing more pain/inflammation
Get your sleep quality high BEFORE your surgery to minimize sleep disturbance afterwards. Download my sleep book (linked below) to help
Follow a low inflammation diet with healthy, whole foods
Organize your house and support network ahead of time
Work on mindset and preparing yourself mentally for the journey ahead
DOWNLOAD MY GUIDE TO SLEEPING BETTER AFER KNEE REPLACEMENT
Click 'Download PDF' below to download to your device
INCISION AND BANDAGE CARE
We try to make incision and bandage care as easy as possible for you after surgery!
Here's how we do it:
When we close your incision, we use dissolvable sutures that don't need to be removed
On top of that, we place a small mesh dressing that helps the skin heal, similar to skin glue
On top of that, we place a bandage that look like a big band aid, called a Mepilex
Finally, we wrap your leg in a layer of wool bandage (called webril) and an ACE wrap
The day after your surgery, you may remove the outer ACE wrap and wool layer dressings, until you see the big Mepilex band aid bandage
Keep the Mepilex bandage in place for 7 days after surgery. You can shower with this bandage in place (it's waterproof), but don't soak it in a tub
After 1 week, a wound care nurse should come visit you in your home to remove the Mepilex. They will take off your bandage and check your incision (leaving the underlying mesh tape in place). If the nurse doesn’t come, you can simply remove the Mepilex yourself after 1 week, and then leave just the small mesh tape in place (you can shower with the mesh, it's also waterproof). This can stay on until you see me in the office 2 weeks after surgery
Some patients will have a more robust surgical dressing called a Prevena. This looks like a big purple bandage with a sticky layer over it, and it's connected to a cannister that keeps a vacuum seal on the incision. If you're going to get this bandage, I'll usually let you know ahead of time. (most patient won't need this dressing)
If you have a Prevena, you can still shower with it as the dressing itself is waterproof. However, you'll need to keep the cannister dry by putting it out of the water
The battery for the suction cannister will last for one week. At one week, a wound care nurse will come to your hosue and remove this dressing and change it to a regular bandage. If the battery dies before the wound care nurse visit, or if you do not get a visiting wound care nurse, just cut the cord a few centimeters away from where it connects to the purple dressing, and throw the cord and canister in the trash. You can then leave your purple dressing in place until the wound care nurse comes, or until you follow up in the office with me
It is normal to see some redness along your leg around your surgical incision. This will gradually improve with time. A small amount of drainage on your bandage that stops within a day or two is normal and nothing to worry about
Bruising and swelling throughout the entire leg are normal after surgery and can travel down your leg and into your ankle and foot. Don’t be alarmed if this happens - it's normal!
Post Op Medications
You can restart your normal home prescription medications starting the day after surgery
The exception is with anti-inflammatory medications (e.g. Ibuprofen, Naproxen, Meloxicam, etc.), because we will be prescribing one for you after the surgery (unless you can't take them for medical reasons). If you're taking one of those NSAID medications, stop taking it and take the meloxicam I have prescribed for you instead.
We have put together a curated, evidence-based medication regimen to help you recover from surgery. While it may seem complicated at first, it's actually not so bad once you realize that most of the meds stop after the first 2-3 weeks, and several of them are only to take as needed (which means you may not need to take them at all)
Most importantly, for the first month after your surgery, there are 3 medicines that you should take consistently, even if you're feeling fine and not in pain:
Aspirin - Prevents blood clots
Take One 81mg tablet (baby aspirin) twice per day for 4 weeks to prevent blood clots.
Start taking this the day after your surgery.
Don’t take this if you’re on another blood thinner such as Eliquis or Xarelto. In that case, you will return to your regular blood thinner after surgery, but we may have you on a lower dose for the first week to prevent too much bleeding. We will prescribe you the amount to take.
Acetaminophen (Tylenol) - Baseline pain and fever control
Take two 500mg tablets every 6 hours consistently while you're awake for the first 4 weeks after surgery. You don't need to wake up in the middle to the night to take these, just take them during the day when you're awake.
You can start this the same day of surgery.
Meloxicam (Mobic) - Reduces inflammation
Take one 15mg tablet per day consistently for the first 4 weeks after surgery. You can start this the morning after your surgery.
We won’t prescribe this if you are on a blood thinner like Eliquis/Xarelto or have kidney disease.
In addition to these three medications that will last the entire month, there are several others that we want you to take the first few days/weeks after surgery:
Cefadroxil (Duricef) - Antibiotic to prevents infection
Take one 500mg tablet twice per day (morning and night) for the first 3 days after surgery. You can start taking this the day after surgery.
If you stayed overnight at the hospital and got IV antibiotics after surgery, we may not give you this medication.
Tranexamic Acid - Reduces post op bleeding/swelling
Take two 650mg tablets twice per day (morning and night) consistently for the first 2 weeks after surgery. You can start this the day after surgery.
This is an excellent medication that helps keep your post op swelling and bleeding low.
Journavx (Suzetrigine) – Frontline pain control
Take 2 50 mg tablets the morning of surgery right before you come to the hospital. You can also bring the bottle of pills with you to the hospital on the day of your surgery in case you end up staying overnight at the hospital.
After the initial dose, take one 50mg tablet twice per day (morning and night) consistently for the first 2 weeks after surgery
The second dose can be taken in the evening on the same day as your surgery (later that same day).
This is an excellent non-narcotic medication that helps keep post op pain well controlled.
Take this twice a day for the first 2 weeks whether you have pain or not. The goal is to use this as our main pain medication and limit the number of tramadol and oxycodone that you take.
Pregabalin (Lyrica) - Reduces nerve pain and helps sleep
Take one 200mg tablet at bedtime for 3 weeks after surgery
This is a nerve pain medication that also makes you drowsy, so only take it at night before bed. On the plus side, it should help you sleep better!
Note that all of the above medications only last for the first few days or weeks and then drop off.
Finally, we have a few medications that you only take as needed. Our goal is hopefully you don't need them, but we prescribe them for you, just in case. These include:
Tramadol - Reduces uncontrolled pain
Take one 50mg tablet every 6-8 hours only if needed for moderate pain for 2-4 weeks or less.
If you're taking the other medications and your pain is getting worse and not controlled, take one of these as a 'rescue' medication to try get your pain under control. Take this first before you take an Oxycodone
This is a less dangerous narcotic medication that isn’t as addictive and doesn’t have as many side effects as Oxycodone.
Oxycodone - Rescue medicine for unctontrolled severe pain
Take one 5mg tablet every 4-6 hours only if absolutely needed for severe pain
This is a narcotic medication that can be habit forming and has many harmful side effects. Our goal is for you to avoid taking this if at all possible. It is a last resort medication if your pain is escalating and you've tried Tramadol, which still isn't working
With these stronger narcotic medications, our goal is to minimize how many you take and wean you off of them as soon as possible after surgery. Ideally, you want to try take less than 10 oxy/tramadol in total.
Ondansetron (Zofran) - Relieves nausea
Tale one 4mg tablet dissolved under your tongue if you’re feeling nauseous
You only need to take this if you're having post op nausea or vomiting. If you’re not nauseous, you don’t need to take this
Don’t take more often than every 8 hours
Senna with Docusate Sodium- Relieves constipation
Take 2 tablets every 12 hours, only if you’re taking narcotics
Narcotics cause constipation, so only take this medication if you’re taking tramadol or oxycodone and it's constipating you. If not, you won’t need this
If this is not enough and you’re still constipated after taking it, add MiraLAX (available over the counter) 17g daily by mouth with a full glass of water
REHAB PLAN AFTER SURGERY
To help minimize swelling and control pain, we are going to keep your activity VERY limited for the first few weeks after surgery
This may seem counterintuitive or different than the rehab programs that you’ve seen other people do after their knee replacement, but it is based on good evidence and is designed to make your recovery easier and less painful
The overall plan is VERY simple:
I want you to limit your steps per day after surgery. Walking/activity causes swelling and inflammation and we are trying to keep that low at first, so we want to minimize steps and build them up gradually
You can track your steps with your phone or with a smart watch or cheap pedometer that can count steps. With each passing week, the step count will get higher
At first, it will be hardly any walking at all - in fact, the first week you're only taking 750 steps a day, which is VERY few. As time goes on, you will gradually walk more and get back to doing all your normal activities
Here is the daily step count limit for every week after surgery:
Week 1: No more than 750 steps per day
Week 2: No more than 1200 steps per day
Week 3: No more than 2000 steps per day
Week 4: No more than 2750 steps per day
Week 5: No more than 3500 steps per day
Week 6: No more than 4500 steps per day
Week 7 onwards: Increase by 1000 steps per day with each passing week until back to your normal levels
For the first two weeks after surgery, there is a simple routine that you should follow every hour you're awake:
Ice and elevate your leg for 40 minutes out of every hour you’re awake
After you’ve done this, get up and walk 10-20 steps. This basically means getting up out of your chair, walking to the edge of the room and back or to the bathroom/kitchen and back. If you just take these small walks, you will minimize the risk of a blood clot while keeping your step count very low
For the remaining 10 minutes of the hour, do the range of motion exercises shown on the handout below at home on your own. This means you will be doing a set of these exercises about 10-15 times a day. So even though you aren't doing formal PT, you are still doing PLENTY of exercises on your own at home
In the section below this, I've included a handout that shows illustrations and descriptions of all the exercises you need to do. In the top right corner of the handout there is a link to a video that you can watch where all of them are clearly demonstrated. Make sure you watch this!
That's all you need to do for the first 2 weeks. It's going to be quite repetitive and boring but if you follow it you will hopefully find that your pain and swelling are well controlled and you get your range of motion back quickly. Keep swelling and inflammation low is the #1 goal of the early post op period
Plan on being off work for a while. If your job involves sitting at a desk all day, you can return to work 4-6 weeks after surgery (if you’re ready)
Jobs that require being on your feet or manual labor will require a minimum of 6 weeks off work and likely more. You may be able to return to light duty sooner
RANGE OF MOTION EXERCISES FOR AFTER SURGERY
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COMMONLY ASKED QUESTIONS
When will I be able to get up and walk?
Right away. Physical therapy will get you up and moving and show you how to use your walker and navigate stairs before leave the hospital. You will not be bed-bound!
Do I need to use a cane or a walker?
Yes. For the first two weeks after surgery, I want you to use a walker, even if you're feeling great with minimal pain. Mostly, it's a reminder to take it easy and go gentle on your body as you're recovering. Once those two weeks are up and I've seen you for your two-week post-operative visit, then we can wean to a cane (or potentially at home, not using anything at all). I do recommend taking a walker or a cane with you when you leave the house for the first few months.
When can I drive?
I clear you to start driving at three weeks for a right knee, and at two weeks for a left knee, assuming you're driving an automatic car. When you first start driving, take your car to a very quiet street or a parking lot and test out doing an emergency stop, because that's really what you need to do to be safe. When you feel that you can adequately do that, if need be, then I think you're ready to get back on the road.
When can I get back in the pool/hot tub/bath?
4 weeks after surgery. I like to give the incision a full four weeks to completely heal before we soak it in water.
When can I have sex again?
This completely depends on you and when you feel ready. I would say for the first week or two, probably better to avoid it and just focus on recovery. After that, it's totally fine. Just be smart about it and use positions that prioritize you and your comfort.
When can I get dental work and what restrictions do I have on that front?
Please hold off on dental work for about three months after surgery. After that, it's okay. But before you go and get dental work done, I want you to let my staff know and we'll send you an antibiotic to take about an hour beforehand. I would like you to take those antibiotics for the rest of your life before dental work just as a precautionary measure.
When can I go back to work?
This is very variable and I have some people that work from home and get back to work relatively quickly, while others who work in manual labor type jobs will take longer. In an ideal world, I would love for you to take six weeks just focused on you and your recovery. But if that's too much time and you can't make that work, then let me know and we can have a discussion about it. Certainly for the first two weeks, because we have that low step count, I want you at home and I want you doing that icing and elevating. Beyond that, if you can work from home, let me know and you and I will come up with a plan together.
When can I get back to higher level activities like working out/running/high impact sports?
For most people, around the three-month mark is when you can really start pushing things and getting back to those kinds of activities. Long term, I have no restrictions on you after joint replacement surgery. I want you to go back to doing the things that you love. Just remember that you need to work your way up to it thoughtfully over time as you recover.
ADDITIONAL RECOMMENDED ITEMS TO HELP RECOVERY
There are several other things that I recommend that you get in order to help your recovery be as easy as possible.
1) An Ice Machine
There is a company that we work with called Pontem who will mail you (covered by insurance) a Velcro wrap with ice packs for your knee.
These are helpful for later on in your recovery when you're driving around, but at the beginning, when you're icing for 40 minutes out of every hour, they're not going to be enough because you're going to have to keep changing them out as they melt. So I HIGHLY RECOMMEND that you get an ice machine.
If you want the highest quality ice machine, my recommendation is the Breg PolarCare Wave. It gives both cooling and compression to your leg, which massively helps your recovery.
The downside of this machine is that it is expensive ($350). However, every patient of mine who's bought it has come back and told me that it was completely worth the investment, so if you can't afford it, I do recommend it, and I have a link below that you can click to get yours.
If you can't afford that price, there are cheaper ice machines for about $150 on Amazon that don't have compression but are also very good.
2) EdemaWear Compression Stockings
These breathable, mesh material compression stockings are much more comfortable than normal compression stockings, and will greatly help your swelling.
The cheapest place to buy them is on the company website. They have sizing guidelines where you can measure the circumference of your thigh to find the right size sock for you. Make sure you purchase the thigh high version.
3) Diosmin and Hesperidin Supplement
This is a naturally occurring compound that's found in citrus fruits that helps prevent swelling, inflammation and fluid buildup in your legs.
You can buy it on Amazon and start taking it right after surgery as directed on the bottle.
4) Essential Amino Acid Supplements
This is really important because these are the building blocks to allow your body to repair and rebuild after surgery.
This helps make the recovery easier, and interestingly, the research shows that it improves pain control too.
Download the handout below to see more details about each of these products along with links and QR codes you can scan to purchase them.
RECOVERY AIDS I HIGHLY RECOMMEND
Click 'Download PDF' to download
Download PDF