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Total Knee Replacement Guide

  • Knee Anatomy

  • Knee Arthritis

  • Knee Replacement

  • Registration

  • "Pre-Op" Area

  • Operating Room

  • Recovery Room

  • Home Needs

  • Post-Operative Issues

  • Pain Management

  • Activity Level

  • Physical Therapy / Mobilization

  • Icing

  • Blood Clot Prevention

  • Driving

  • Sleep

  • Nutrition

  • Bathing

  • Follow-up

  • Review the Risks associated with surgery

  • Review risks

  • Contact Info

  • Helpful Information

  • Length of Stay

  • Treatment Team

  • Pain Management

  • Physical Therapy

  • Occupational Therapy

  • Dressing Changes

  • Blood Clot Prevention

  • Who to Call for Concerns

  • Medication Refills

  • Antibiotics for Dental Work / Procedures

  • Flying

  • Flu and Vaccines

  • Massage / Acupuncture

  • Intimacy following Surgery

  • Physical Therapy Protocol

  • Medical Clearance

  • Pre-Op Medications

  • What to Pack

  • Day Before Surgery

  • Morning of Surgery

  • Blood Donation

  • Determination of Discharge

  • Equipment and Medications for Home

  • State Disability

  • DMV Placards

  • Jury Duty

  • Additional Form Requests

  • Exercises to do on your own

Brief Background

The knee joint is comprised of 5 structures:  The inner compartment between the femur (thigh bone) and tibia (shin bone), the outer compartment between the femur and tibia, the knee cap, and the 2 cruciate ligaments that keep the knee stable. The femur and tibia are both lined by cartilage which allows for smooth and painless motion.  Additionally, a thick layer of cartilage (the meniscus) sits between the femur and tibia and serves both as a cushion to absorb shock and an additional structure to keep the knee stable.

Knee Replacement.jpg

(Left)  Normal Knee Anatomy  (Center) Total Knee Replacement.  The arthritic cartilage and underlying bone has been removed and resurfaced with metal implants on the femur and tibia.  A plastic spacer has been placed in between the implants. The patellar component is not shown for clarity.  (Right)  In a partial knee replacement, only the damaged compartment is replaced with an artificial device.

Knee arthritis is a disease that involves loss of the cartilage over time leading to bone-on-bone contact between the femur and the tibia. This causes pain, loss of motion, poor balance as stability deteriorates, and impairment of activities. 

Knee arthritis develops in patterns.  Some patients develop arthritis that affects the entire knee; these patients report having pain “all over” the knee.  Others only wear out the cartilage on either the inner or outer compartment of the knee.  Patients who have only worn out one compartment of the knee report having pain isolated to that side.  If the pain is isolated, a patient may be a candidate for a partial (unicompartmental) knee replacement.  If it is global, a total knee replacement may be a more appropriate option.    

Total knee replacement is a definitive and effective treatment for knee arthritis.  A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surface of the bones are actually replaced.

What follows is a detailed packet of information to help guide you through the process of having your knee replaced.  Please read it carefully and do not hesitate to contact our office with any questions you may have.   Thank you for choosing the Bone and Joint Center at HPH for your upcoming total knee replacement procedure. The Bone and Joint Center at HPH with their orthopedic team are excited to participate in your care.

(Left)  Components of a Total Knee Replacement.  A thin layer of damaged bone and cartilage from the femur (thigh bone) and tibia (shin bone) are removed to allow a new surface to be placed on each end.  These parts are sized to match the bone and to "straighten" the leg when they are placed on the bone.  Generally, these parts are "glued" to the bone with a special bone cement.  A special type of plastic called "polyethylene" is used to make a "spacer" that is placed between the metal ends.  This makes helps tension the ligaments to make the knee more stable and to keep the metal ends from rubbing into one another.  (Right)  What the total knee looks like once it is finished.


Scheduling Surgery

Helpful Information for Scheduling Surgery

When you are ready to schedule surgery, you may do so by calling our surgery coordinator at (808) 522-4232 or schedule at any of your appointments.

  • By default, knee replacement surgery is considered "outpatient" surgery.

  • Depending on your overall health, your knee replacement will be scheduled as an "outpatient" surgery in either the hospital or the ambulatory surgery center (ASC).

  • We will attempt to give you a definitive time for surgery when you book your date at your consultation.

  • In the event you want to book your surgery after your consultation at a later time, speak with your surgeon’s medical assistant or the surgery schedulers.  You can contact them via the number above.

  • In the event that multiple patients are scheduled on the same day, the scheduler may not schedule a specific time for surgery as the schedule has a tendency to change (due to illness, medical/social complications, etc.).   

  • In this event and in order to minimize confusion, the time of your surgery may not be determined until 48-72 hours prior to your scheduled date. 

  • This is normal.  Do not be concerned as we will certainly contact you prior to your scheduled day and make sure you know when to come to the hospital / ASC. 

  • Please call the scheduler and let them know if you develop a fever above 101° or cough with phlegm production prior to surgery.  These may be reasons to postpone your procedure.  If you have a runny nose or a post-nasal drip cough, it is okay to proceed with surgery as scheduled.

  • Another reason to postpone your surgery may be due to any type of rash or open/scabbing wound around surgical site.  Please call our office as soon as possible to have your surgeon or his physician assistant evaluate the area of concern and determine if surgery needs to be postponed.

  • If you change your mind about the date of your surgery, please give our office the courtesy of at least 7 days notice so that another patient may be able fill your spot.  

Scheduling Surgery

​Preparing for Surgery

Pre-Operative Medical Clearance

  • You should make an appointment to see your internist / primary care physician for medical clearance 2-3 weeks prior to your surgical date.  If your physician is not available during that window or you would prefer to see one of the HPH physicians who work with us routinely, we will attempt to make an appointment for you when you schedule your surgery.  

  • If you will be seeing your own internist, let the scheduler know who that will be and give them her/his contact information.  The scheduler will fax that doctor’s office a list of everything we need for your surgery clearance.  Our office staff will follow-up with your doctor to ensure all records are received.  It is necessary for our office to receive these records at least three (3) days prior to your surgery, in order to forward them to the hospital.  If we do not receive your clearance in a timely manner, your surgery may need to be postponed.

  • Please take a complete list of your medications to your pre-operative appointment for review.  You may be asked to stop certain medications prior to surgery. 

  • If you have a history of heart problems (i.e. history of heart attack, angioplasty, stent placement, bypass surgery, valve problems, abnormal heart rhythm, and/or pacemaker implantation) please make an appointment with your cardiologist for cardiac clearance.  This appointment should be scheduled before you see your internist.

  • You will have a pre-operative appointment with the surgical team 1-2 weeks before your surgery date.  At the pre-operative appointment, you will meet with a Physical therapist, our surgical scheduler, and physician assistant / surgeon.  Depending on your appointment, you may also be meeting with the pre-operative nurse, hospitalist, and anesthesiologist that same day. Please expect to be at the hospital anywhere from 4-6 hours.

Recruiting a Caregiver
  • We anticipate that you will be able to take care of your basic needs when you get home from surgery.  However, your surgeon recommends that you have a caregiver before, during, and following your surgery who will be able to help you with certain tasks and will also be available to arrange transportation for you to and from the hospital and to and from appointments.  Caregiver participation before, during, and after hospitalization will help promote a smooth recovery.

  • The role of the caregiver pre-operatively will be to help you plan your pre-operative medical clearance, to provide transportation to and from your appointments, and to help you pack and be mentally prepared for your procedure.

  • If you stay in the hospital, your caregiver will participate in therapy sessions to learn your exercises, help you do the exercises taught by the therapists, provide you with company, and serve as a liaison between you and the nursing staff.  Your caregiver may stay with you in your hospital room during your stay.  The caregiver should be available to provide your transportation home upon discharge.  

  • Once you get home, your caregiver will provide emotional and social support, help you with your exercises, assist with meal preparation and housekeeping, and assist you with your personal care needs as needed.  

  • A caregiver can be a family member, a friend, or a person you hire.

  • If family members are flying in from out of town to help you, they should not need to stay for more than 2 weeks.

  • If you would like to hire a caregiver, please inquire PRIOR to your pre-operative appointment to allow time to coordinate with the appropriate referral network.

​Pre-Op Medications

  • Discontinue any anti-inflammatory medications 7 days prior to surgery.  

    • Anti-inflammatories include Advil, Aleve, Motrin, Ibuprofen, Aspirin, Mobic, Naproxen, Arthro-tec, Lodine, Excedrin, and others.

    • If you are taking Celebrex, you may continue this up until the day of surgery.  

    • During this time, you may take Tylenol, Ultram, or Vicodin for pain.  

  • Discontinue all vitamins, minerals, and herbal supplements 7 days prior to surgery.  

    • These can affect blood clotting properties and can also have adverse effects on wound healing.

    • You may resume these 1 week following surgery.

  • Discontinue any blood thinning medications 5 days prior to surgery if cleared by the prescribing physician.  

    • Blood thinning medications include Coumadin, Plavix, Aggrenox, Heparin, fish oil, Xarelto, Eliquis, Pradaxa, and others.  

    • If you are on Coumadin, please ask your internist or cardiologist if you should be on a short-acting blood thinner during the 5 days you’ll be off of the Coumadin.  

    • If you are on a combination of Plavix and Aspirin, you should stop the Plavix five days in advance, but you may continue the aspirin up until surgery.  

    • In all cases of blood thinners, we will defer to your cardiologist’s recommendations.

  • Discontinue any hormone therapy 7 days prior to surgery.  

    • Hormone therapy has been associated with an increased risk of blood clots.  

    • Surgery is an independent risk factor for blood clots, and we don’t want you at increased risk.

    • You may resume your hormone therapy 1 week after surgery.

Hibiclens Instructions​
  • When you see HPH Bone & Joint Center for your pre-operative appointment, you will be given Hibiclens "wipes" to cleanse your skin prior to surgery.

    • Hibiclens is a solution used to disinfect the skin.

  • Use the Hibiclens "wipes" on the morning of surgery after your shower.

  • It is very important to shower with this both the night prior to surgery and the morning of surgery per the instructions.

  • ​Please use a fresh clean washcloth and towel to dry off each time you shower for the 5 days.

  • Put freshly washed sheets and pillowcases on your bed starting on the 5th day before your surgery.

  • Please put on freshly washed pajamas for sleep each night.  

What to Pack for the Hospital / Ambulatory Surgery Center (ASC)
  • Leave all jewelry (including any body piercing jewelry) at home.

  • Leave all your valuables at home.   Ask your caregiver to bring a credit card or cash to pay for any discharge items or prescriptions.

  • Bring your ID and insurance card. 

  • Bring your list of medications.  Do not bring your actual medications unless you are taking a drug that is unusual or difficult to obtain.  If this is the case, you may bring it, but it must be in the original pharmacy container with the drug name and directions on the label.

  • You may bring a cell phone and charger if you would like.

  • Bring a comfortable change of clothes (in the event you stay overnight).  

  • Bring your toiletries (toothbrush, toothpaste, deodorant, hairbrush, etc.) 

  • Bring your glasses and/or hearing aids

  • Bring a book/magazine to pass the time. 

  • Bring your CPAP mask and tubing if you have sleep apnea.

​The Day Before Surgery
  • Prior to surgery, you will be receiving a call from your surgeon’s office with your surgery time and the details of your surgery—where to go, what to bring, what to wear, etc.  We aim to make this phone call about 3 days prior to surgery but it may be sooner or later depending on when you were scheduled.  Please make sure you are available, so you don’t miss this important information.

  • You will discuss anesthesia options at your preop appointment.

  • Shower the evening before surgery.

  • Make sure your hospital bag is packed and ready to go.

  • Do not eat solid food after 7pm the night before surgery.  Liquids are OK up until midnight.

  • DO NOT eat or drink anything after midnight the night before surgery. 

​The Morning of Surgery
  • If you usually take medications in the morning (i.e. for your thyroid, blood pressure, cholesterol, etc) you may take them as usual with only a minimal amount of water.

  • If you have diabetes and control it with medications, do not take your diabetes medications the morning of surgery.  If you take insulin, cut your insulin dose in half the morning of surgery.  Please discuss this with your internist during your medical clearance appointment as we will defer to her/his  recommendations if different from ours.

  • Shower, dry off and use the Hibiclens wipe over the knee area

  • Dress in clean, comfortable, loose-fitting clothes.

  • Brush your teeth, but don’t swallow the water.

Blood Donation
  • It is not anticipated that you will need a transfusion post-operatively.

  • We use a number of methods during surgery to minimize blood loss.

  • We do not recommend pre-operative blood donation.  Donating ahead of time means you will be coming in for surgery with a lower blood count and will be more likely to require a transfusion post-operatively.  There are also risks associated with transfusion of blood.  

  • Please be aware that donating blood before surgery will prolong your recovery as your body will be trying to heal while your blood count is lower.

​The Day of Surgery​

  • You will be instructed to check in at “Surgery Registration” when you arrive at the hospital / ASC.  Your surgeon’s office will let you know what time you need to check in.

  • Once you arrive at the hospital, you should enter through the main entrance of the hospital / ASC.  Self-parking for your driver is available in the parking structure or Valet parking is available from 7:30am to 4pm.  Information desk/volunteer services can direct you to the appropriate location if you need assistance.

  • Once at the hospital / ASC, follow signs to "Admitting".

  • After the admitting process, you will be directed to the Surgical Admission Center (SAC).  A staff member from SAC will meet and escort you to the area where you will be prepared for surgery.

What Happens in the “Pre-Op” Area


  • Once you’re in the “pre-op” area, you will be asked to change into a hospital gown.  A nurse will review your medical history with you and start your IV.

  • Your knee will be washed and shaved.

  • Your anesthesiologist will see you to discuss anesthesia options.

  • Your surgeon or the physician assistant will stop by to see you and mark the knee we will be replacing.

  • Please do not write anything (such as “not this one”) on your opposite knee.

  • The nurse will give you a number of medications before you are taken to the operating room. 

  • Your family may stay with you in the pre-op area but will be asked to wait in the surgical waiting room while you are in the operating room.  Your surgeon will call them after your operation is completed. 

What Happens in the Operating Room


  • There are 2 available options for anesthesia.  You and your anesthesiologist will choose which is best for you. 

    • General anesthesia — with this option, you are completely asleep and may have a breathing tube inserted to help you breathe during surgery.  

    • Spinal with sedation — with this option, you will have the anesthetic put in your lower back.  This will numb you from the waist down.  In addition to this, you will be given a sedative through your IV so that you will be in a “twilight sleep” during the procedure and will be unaware of being in the operating room.  Some patients may not be eligible for this option if they’ve had prior back surgery, if they have a severe curve in their spine (scoliosis), if they are very obese (which makes administering the anesthetic technically challenging), or if they have a skin infection overlying the area of spinal administration.  

  • Regional Block - A local anesthetic may be administered by the anesthesiologist that will numb or block the pain sensation around the area of the surgery.  

  • Our patients do very well regardless of which anesthetic option they choose.  Our selected anesthesiologists are very skilled and there is not one who we would recommend over another.

  • You will discuss your anesthesia options and plans at your pre-operative appointment and in the pre-op area.


Catheter Placement

  • We generally do not use a catheter for primary knee replacement surgeries.

  • In rare events, after anesthesia is administered, a catheter MAY be placed in the bladder that will be discontinued either in the recovery room or the day following surgery depending on your age and medical history. 

IV Antibiotics

  • You will receive antibiotics through your IV immediately before surgery.

  • Antibiotics may be continued after surgery for a short period while you are in the hospital / ASC.

  • You will not need antibiotics after discharge. 

What Happens in the Recovery Room

  • After the surgery, you will be closely monitored in our recovery room for approximately 2 hours. 

  • The recovery nurses will make sure your vital signs remain stable and your anesthetic is wearing off appropriately.  They will also give you pain medication as needed.

  • The nurses will apply ice packs to your joint.

  • If you are being discharged home, you will practice walking.

  • Once you meet certain criteria, you will be discharged home or transferred to the orthopedic floor (if needing further monitoring while in the hospital).

    • Your family may meet you once you arrive in your designated room, if you are brought into the hospital.​

Preparing for Surgery
Day of Surgery

The Hospital / Ambulatory Surgery Center (ASC) Stay

Length of Stay
  • Total Knee Replacement surgery is now considered "OUTPATIENT" surgery by default.

    • This means if you meet certain criteria, you will be discharged home on THE DAY OF SURGERY

    • ​If you are motivated to go home the DAY OF SURGERY, you should be medically stable to do so with your pain controlled.

  • It is recommended that you return home as soon as it is physically possible as short stays in the hospital are associated with better outcomes than longer stays.

  • In order to go home, you must meet criteria in 3 areas: function, medical status, and pain management.

    • Function: You must meet certain milestones before discharge so that we know you’ll be safe and able to take care of yourself once at home. 

      • Be able to get in and out of bed without assistance.

      • Be able to go to the bathroom on your own.

      • Be able to change your clothes without assistance.

      • Be able to go up and down stairs 

    • Medical status:  You must be medically cleared by the internist.

    • Pain management:  You must be able to manage your pain on oral pain medications. 

  • If you meet all 3 criteria, you may go home the day of surgery or at the latest, the following morning.

  • Some patients (< 10%) require a second night in the hospital.  

    • It is entirely based on medical necessity and not for convenience.  

    • Please note, we cannot keep you in the hospital if you are medically and physically cleared to go home.

  • In only RARE occasions, a rehab / SNF hospital stay may be necessary for recovery.  

    • This is more the exception than rule for a primary joint replacement surgery.

Who will check on me during if I stay in the hospital?

  • Your surgeon and/or a team member will check on you daily.

  • Our Nurse Practitioner Hospitalist will come see you daily to ensure you are doing well medically.  

  • If your primary doctor is on staff at the hospital, they can see you if you arrange this with them prior to your stay. ​



Pain Management

  • Our goal is to encourage you to manage your pain in a way that allows you to be functional for your activities of daily living and able to participate in physical therapy activities.  

  • The goal of pain management is not to make you pain free, as this is an unrealistic expectation following major surgery.

    • On a scale of 1-10, we expect that with an appropriate pain management approach, you will have a baseline pain score of 3-4.  

  • It is important to understand that taking pain medicine optimally requires finding a balance between pain control and side effects (nausea, constipation, mood changes, slowed thinking, dulled reflexes, etc.).  For this reason, we do not recommend taking pain medications at scheduled times around the clock, but rather on an as-needed basis (especially after 72 hours from surgery).

    • In the first 72 hours, you may need scheduled narcotic pain medicine, but you should attempt to limit this as your pain subsides.​

  • At the end of surgery, we routinely inject a local anesthetic in the tissues around the knee with the goal of having you wake up comfortable.

  • As the local anesthetic effect wears off, you will start to perceive pain. When you start to feel pain, you should start taking oral narcotic medicine if your pain is not tolerable with Tylenol alone.  

  • Keep in mind that pain medication will decrease your pain score by about 3. 

    • Generally, we do not recommend waiting until your pain is a 9-10 before taking narcotics.

      • If you wait until your pain is a 10, you will be chasing the pain with many medications and will have a difficult time getting back down to a tolerable score.  ​

    • Conversely, you may not need narcotics if your pain is a 2-3 because making your pain "0" is not realistic with pain medication.

  • You should continue to take your pain meds as needed to keep your pain tolerable – as often as every 4-6 hours if you require them that often initially    

  • The medications we order include, Oxycodone, Norco or Vicodin, Tramadol, and Tylenol.  Which medication(s) you are given depends on how much pain you’re having when you call the nurse.  

  • If you have a history of chronic pain and take strong pain medications routinely, we will try to coordinate your pain medicine with your pain management specialist.

  • As your pain subsides in the days after surgery, you should expect to decrease the number of pills and frequency in which you take them.

  • Unless contraindicated, we recommend you take Tylenol 650mg every 6 hours as long as you are experiencing ANY pain for the weeks after surgery.

Physical Therapy (in the Hospital)

  • You will receive physical therapy two times per day—even on weekends.

  • Physical therapy will typically begin on the day of surgery.  If your surgery is late in the day, you will walk with a nurse that evening and begin your formal therapy the next morning.

  • The physical therapist will work with you on your motion and strength exercises and will also teach you how to transfer in/out of bed, in/out of a chair, how to walk symmetrically, and how to navigate the stairs.

  • All patients walk with a walker the first day.  

  • You can transition to a cane when you feel completely "stable" on a walker.

  • Unless told otherwise, you may put your full weight on your operated leg.  The prosthesis is solidly fixed.  It will support you.  If you are uncomfortable, you may transfer some weight to the walker/cane.

Occupational Therapy (in the Hospital)

  • You will receive occupational therapy once daily.

  • You will have a chance to shower with an occupational therapist for assistance prior to your discharge. This is not a requirement for discharge.  

  • You may shower on the 2nd day after your surgery.

Dressing Changes

  • This will depend on the type of dressing you have in place.  Your surgical team will clarify which dressing you have in place and the instructions for care.

  • Generally, there are two "types" of dressings

    • Gauze / Tape style dressings that are generally removed at 2 days from surgery​

    • Occlusive, negative-pressure, dressings that stay on for approximately 7 days and generally have a "suction" unit attached to them (ie the PICO dressing)


    • Your dressing will be removed 2 days after your surgery and your dressing will be changed daily after that. 

    • You will likely be able to shower on the 2nd day after surgery (unless advised otherwise) with your dressing removed.

      • Your skin may be sealed with a type of skin glue called “Dermabond” or with staples or ex-ternal sutures.  All wounds have deeper layer sutures that will dissolve over time.

      • Do not scrub your wound with any brushes or clothes until advised by your surgeon.

      • Staples are removed at approximately 2 weeks from surgery at your post-op appointment.

    • It is best to keep a dressing between your clothing and the incision during the first two weeks after surgery.  This is to allow the wound to heal without irritation developing from your clothing rubbing against it.  


    • This dressing will stay in place for 7 days to keep the wound sterile and dry. 

    • If there is an "error" indication on the suction unit, the dressing will need to either be addressed to correct the error or it will need to be removed in 24-48 hours from the time the unit stopped working.

      • Note, if the suction unit stops working, it is not an "emergency."  It generally can be addressed in 24-48 hours as long as it is ultimately resolved.

      • Please contact the office at - 808-522-4232 and speak to the medical assistant to troubleshoot such errors.

      • Please see the discharge instructions below for specific instructions on the PICO dressing.

Blood Clot Prevention

  • Your highest risk period for developing a blood clot in your leg is the first 48 hours after surgery.

  • We will use a number of strategies to minimize this risk

    • We will get you up and walking the day of surgery.  This keeps the blood moving. Just as a flowing river doesn’t freeze, flowing blood is unlikely to clot.

    • You will have devices on your calves while you are in bed which will periodically squeeze the calves so blood cannot pool in your lower legs.  

    • You will be started on an aspirin (or blood thinning medication) regimen to keep the blood thin.  This will be continued for 4 weeks following surgery.  If you are intolerant to aspirin or were on a blood thinner pre-operatively, this regimen will be modified and/or a different agent will be used.

Hospital Stay

The Day of Discharge

Determining When Discharge Will Occur
  • In order to be discharged, all the members of the medical team (your surgeon, internist, and physical therapist) need to agree that you are medically and functionally ready to go home.  You must also be able to manage your pain with oral pain medications.

  • Most patients are discharged HOME on the DAY OF SURGERY.

  • Patients are usually discharged at 11:00 am on the day of discharge 7 days a week if staying overnight.  

    • Please make sure your caregiver is available to provide transportation home at that time.

  • On very rare occasions, a patient may need to go to a short-term rehabilitation facility for additional physical therapy before going home.  

    • In this circumstance, the case manager on the orthopedic floor will make all the necessary arrangements.  

    • Please note, most insurances DO NOT cover short-term rehabilitation for a routine total joint replacement in a relatively healthy patient.

  • Your nurse will provide you with a list of discharge instructions from your surgeon. Please read them carefully—they are also included at the end of this brochure.

Equipment and Medications for Home
  • What you need will be determined by you and the physical and occupational therapists.  You do not need to purchase equipment ahead of time.  Please be aware that insurance may not cover some items.  If this is an issue, please discuss it with the vendor supplying the equipment.

  • You will be prescribed extra dressings however regular gauze will work fine.

  • You will get a list of exercises you should do twice daily when you get home.  

  • Please note, your surgeon does not routinely order a CPM machine for his patients, as the literature does not support its use. 

  • “Cold Therapy” (aka “Ice Packs”)

    • Icing your knee following surgery is strongly recommended for the reduction of post-operative inflammation and pain. 

    • Apply cold therapy (Ice packs OK) to your knee any time you’re not walking or doing exercises during the first 3 weeks.  After 3 weeks, you should still use cold therapy after exercises and before going to bed for an additional few weeks (until you can no longer feel heat over the knee following activity).

  • A number of prescriptions will be given to you.  

    • Pain medication - typically oxycodone or tramadol.

    • Ecotrin (coated aspirin) to be taken once daily after meals for 4 weeks.  (This is sometimes written as EC-ASA).

    • Prevacid 30 mg or a substituted acid blocker covered by your insurance to be taken once daily to protect your stomach from the aspirin.

    • If you have a history of ulcers, bleeding from the intestine, or as aspirin allergy, an alternative to aspirin called Persantine can be given to you. Take it 3 times daily for 4 weeks.

    • If you have a history of a blood clot, you may be given medications called Xarelto, Eliquis or Lovenox.  This will be taken once a day for 4 weeks.

    • If you are on Coumadin, you will be resumed on it directly following surgery.  Once your Coumadin thins your blood to the appropriate level, you will not need to take aspirin or Prevacid in addition to the Coumadin.

    • You will not be given a prescription for antibiotics for home.  The scientific literature shows this is unnecessary.  

Day of Discharge

The Post-Operative Course

Will I Need Help at Home?
  • We anticipate that you will be able to take care of your basic needs when you get home from surgery.  However, your surgeon recommends that you have a caregiver before, during, and following your surgery who will be able to help you with certain tasks and will also be available to arrange transportation for you to and from the hospital and to and from appointments.

  • Caregiver participation before, during, and after hospitalization will help promote a smooth recovery.

  • Once you get home, your caregiver will provide emotional and social support and will also help you with your exercises, assist with meal preparation and housekeeping, and assist you with your personal care needs as needed.  

  • A caregiver can be a family member, a friend, or a person you hire.

  • If family members are flying in from out of town to help you, they shouldn’t need to stay for more than 2 weeks.

  • If you would like to hire a caregiver, the case managers can assist you in making arrangements.

    • This should be arranged BEFORE your day of surgery.

Changes in Blood Pressure, Temperature and Skin after Surgery
  • During the first 10 days to 2 weeks after surgery, it is not unusual to experience fluctuation in blood pressure.  This is your body’s way of responding to the stress of surgery.  Blood pressure can be low at times or higher than your baseline.  This will settle down over a couple of weeks.  If it is consistently high, you should call your internist / primary care physician for recommendations.

  • Temperature can fluctuate as well.  As long as your temperature does not exceed 101.5°, you should try Tylenol to reduce it.  

    • Make sure you do not exceed 4000 mg of Tylenol in a 24 hour period (less than 3000mg is ideal).

    • Many pain medications (Percocet, Vicodin, Norco, etc.) contain 325 mg of Tylenol, so please take this into account when calculating your Tylenol intake.  

    • A temperature DOES NOT automatically mean you have an infection.  

  • Inflammatory changes, including redness and warmth, affecting the skin around the incision are normal and expected for weeks after surgery especially after activities. 

  • Redness, heat, pain, swelling, and a low-grade fever following surgery ARE NOT always indications of an infection.  

    • If you have concerns about these, please call your surgeon’s office at (808) 522-4232, NOT your internist.  

    • Doctors unfamiliar with normal post-operative changes may misinterpret these as signs of infection and prescribe antibiotics.  


Bruising, Swelling, Weight Gain, and Frequent Urination

  • Bruising of the leg is normal following knee replacement surgery.  

    • The bruising is usually in the back of the leg and/or inner thigh and can extend from the knee to the foot.  

    • Bruising is at its worst 2 weeks following surgery.  

    • Please do not become alarmed if you notice bruising developing during this period.  

    • Although it can look dangerous, it is generally not to worry about and will resolve on its own.

  • Swelling of the leg is normal.  

    • You will notice that the amount of swelling you have will increase in the few days after you get home.  

    • This is because you will be up on your feet more than you were in the hospital.  

    • Gravity will pull the fluid you’re retaining down into your leg.  

    • The operative leg may be 1 ½ times the size of the other leg.  

    • The best way to reduce the swelling is to elevate your leg as high as you can any time you are resting.  

    • The more of a downhill slope you can create, the faster gravity will pull the fluid out of your leg.

    • Try to have your ankle higher than your knee and your knee higher than your hip.  

    • It is okay to put a pillow under your knee if you find it more comfortable to elevate your leg this way.

    • Some patients find it helpful to use a “wedge pillow” to elevate their leg.  

      • This can be purchased at most medical supply stores.

  • Patients frequently report that they weigh 8-12 pounds more in the days following surgery.  

    • This is due to the extra fluid you are retaining (the swelling in your leg).  

    • Your weight will return to baseline once the extra fluid is filtered out of your body.  

  • As your swelling subsides, do not become alarmed if you are urinating more frequently.  

    • This is your body’s way of eliminating the extra fluid.  

    • It does not mean you have a urinary tract infection.

  • Most of the swelling should resolve in the first 4 weeks after surgery but may take up to 12 weeks.

Pain Management

  • Post-operative pain is the result of inflammation from the procedure and changes in activity level as you heal.  

    • Inflammation generally takes the form of pain, swelling, redness, and heat (especially after activities).  

    • A normal post-operative knee will continue to be inflamed to some degree for up to approximately 12 weeks following surgery (the early healing period).  

    • Inflammation from the surgical procedure itself usually peaks about 3 days after the procedure.  

  • It is important to be aware of this because most patients are discharged from the hospital while the inflammation curve is still on the rise.  

    • This means you will have more pain and swelling in the few days after you get home than you did in the hospital.  

    • This is normal and expected. 

  • You should take your pain medication as needed.  

    • As stated in the in-patient pain management section, it is important to take your pain medicine before your pain becomes unbearable.  

    • The sooner you take the medication, the more effective it will be.

  • Do not be stoic and try to “grin and bear it”.  It is more important to manage your pain so you can be more active.  

    • Again, the goal is not to make you pain free, but rather to have a baseline pain score of about 3-4.  

  • In order to manage your pain effectively in the first few days at home, you may need to increase the frequency of your medication.  

    • If needed, pain medication can be taken every 4-6 hours.  

    • Again, the key words are “if needed”.  

    • You should not take pain medicine before you need it (pain less than 3 or 4) as this will increase your chances of experiencing side effects. 

  • Please be aware that you should not take narcotic medications on an empty stomach.  

    • Always make sure you’ve eaten something before taking pain medicine so you reduce the chance of nausea.  

  • Please do not be overly concerned about becoming addicted to the pain medication.  

    • Multiple studies have shown that patients generally do not become addicted to pain medications in the immediate weeks following joint replacement surgery. 

    • However, prolonged usage (weeks) can lead to dependency.  The goal is to have you off the narcotic pain medicine by approximately 2-3 weeks if possible.

  • Most of the inflammatory pain and swelling you experience will subside in the first 4 weeks from surgery.  

    • You will find that your pain medication needs will taper naturally as you recover.  

  • You should be taking Tylenol from the day of surgery and ultimately may taper off the narcotic medicine, so you are only taking Tylenol.   

    • Make sure you are not taking more than 4,000 mg of Tylenol in a 24 hour period as this may lead to liver toxicity (less than 3000mg is more ideal).

  • Please be aware that most narcotic pain medications contain about 325 mg of Tylenol (acetaminophen), and factor this in when calculating your daily Tylenol intake.   

    • Please do not take Advil, Aleve, ibuprofen, or any other anti-inflammatory while you are on as-pirin unless instructed.  

      • Your blood may become too thin.  

    • Celebrex is okay to take concurrently with aspirin.   ​

    • Once you are finished taking the aspirin (4 weeks after surgery), you may take anti-inflammatories as needed.

  • It is normal to have a “rocky” recovery course.  

    • You will have good days and bad days.  

    • As you continue to recover, you will have more good days and the bad days will taper.

  • You may have inflammatory set-backs as your activity level changes.  

    • These, while uncomfortable, are not dangerous.

    • You will need to slow down, ice and elevate your leg diligently, take your pain meds as needed, and sometimes go back to using an assistive device like a cane or walker until the inflammation subsides.  

    • An inflammatory flare can occur any time during the initial 12 weeks following surgery and may still occur even further out from surgery with prolonged or "aggressive" activity.

  • A useful tip is to increase your walking distance in as step-wise fashion.  

    • Since it takes about 3 days to feel the effects of inflammation, increase your walk in 3-day increments.  

    • If you can walk the new distance for 3 days comfortably, you can increase it on the 4th day.  

    • See the activity level section below for more details.

Activity Level

  • We want you to be active after surgery in order to promote good blood flow and build new muscle memory.  

  • Once you get home, you should not stay in bed all day.  You should resume your daily routine as your comfort allows.

  • You should begin a regular walking program.  

    • Start by walking 5-10 minutes a day.  

    • Every 3 days, you should increase your time or distance as comfortable.  

    • By 3 weeks from surgery, you should be walking 15-20 minutes outdoors comfortably.  

      • By this point, most patients are walking without a cane indoors and only take the cane with them on outdoor walks in case they encounter uneven surfaces or feel fatigued.  

      • You can continue to increase your walking distance as your comfort and endurance allow.  

  • Make sure you increase your activity level gradually, and do your hospital exercises twice a day.  

    • Your knee will initially be stiff from the swelling.

    • As your swelling subsides, your motion will get easier.  

    • Most TOTAL KNEE patients are bending their knee about 85-90 degrees by 4 weeks AND PARTIAL KNEE patients are bending approximately 110 or more by this point.  

  • Keep doing the exercises and the motion will continue to improve.  

    • The majority of your range of motion progress will be made in the first 12 weeks, but you will continue to make gains for 12 months. 

  • Patients who play tennis or golf are usually able to resume these activities once the knee is healed—about 12 weeks from surgery.  

  • Please do not engage in excessive activity (18 holes of golf, singles tennis, difficult hiking, resistance exercises) in the first 12 weeks as this will increase your swelling and slow your range of motion progress.

  • Please do not use a treadmill for your walk until you can walk 1-2 miles outdoors comfortably. 

Physical Therapy/Mobilization 

  • The key to rehabilitating your knee is walking.  

    • As described above, you should start a walking program immediately post-operatively.  

    • Walking will help you with your gait pattern, your balance, coordination, stamina, and strength.

    • The more you walk the better physical condition you will be in.  

    • Please remember to increase your time/distance gradually.

  • You can start working on motion exercises immediately after surgery.  

    • The key to regaining your motion without increasing your inflammation is to do exercises that are low intensity and very rhythmic (many repetitions). 

  • Using a stationary bike without resistance is another option.  

    • For an upright bike, put the seat as high as it will go.  

    • For a recumbent bike, put the seat as far back as it will go.  

      • You will not be able to make a full revolution initially, but practice going back and forth and you’ll quickly progress to full revolutions.

  • There are a number of exercises you should do daily.  

    • They are included HERE.

    • Do them TWICE a day every day after surgery including days you do physical therapy.

  • Generally, a prescription for outpatient therapy will be given to you and set up prior to your surgery but formal physical therapy for a total knee replacement is not always required.

    • If you can take a walk daily and can do some basic exercises, you may not need formal therapy.  

  • We recommend "home exercises" for the first 2 weeks and then starting formal outpatient therapy thereafter. 

    • Having someone aggressively push on your leg to get your knee to bend can be very painful and very counterproductive.  

    • It will only result in increased inflammation and swelling and will result in further stiffening of the knee and potential problems with the wound. 

  • Generally, a physical therapist can work with you 2-3 times a week for about 4-6 weeks for a total knee as an outpatient.  

  • We want you to focus on walking and the basic home exercises during the first 2 weeks.  

    • You may use a stationary bicycle as described above if you wish, but the bicycle should not be a substitute for your walk.

  • You may use a treadmill but walking outdoors is preferred.

  • You may start lower extremity resistance training 6 weeks after surgery but this should start slowly.

  • Only begin "return to normal / higher level" activity around three months from surgery.


  • You should apply cold for at least 30 minutes 4 times a day initially for the first week.  

    • The more you use cold therapy, the more quickly your inflammation will subside.  

    • We recommend utilizing cold therapy any time you’re resting.  

  • You should continue to ice after activities (i.e. daily walk, exercising, running errands) and before going to bed for at least 3 weeks following surgery.

  • Regardless of the type of cold therapy equipment you have, we recommend using a towel or washcloth between the cold pad and your skin.  

    • If you’re using ice packs, make sure you ice for no longer than 30 minutes at a time and allow a period of 30 minutes to lapse between applying ice packs.

Blood Clot Prevention

  • As stated above, you will go home with medication to keep your blood thin and will also have compression stockings to wear.
    Take your aspirin, persantine, Coumadin, OR alternative medication as directed.  It is important to continue for 4 weeks following surgery.

  • Make sure you are being active at home and not resting in bed all day.  Again, activity keeps the blood flowing.


  • Driving can be resumed when you feel ready to get behind the wheel and when you are not taking narcotic pain medications regularly.  

    • This is approximately about 2 weeks for a left knee and 3 weeks for a right knee.  

  • When you feel ready to drive, sit in your car for a few minutes and practice moving your foot from the gas to the break.  Make sure this is comfortable for you.  

  • Do not drive unless you can stop the car immediately.


    • If you are involved in an accident while on narcotic pain medication, you may face criminal charges even if the accident was not your fault.

  • The first time you drive, only drive a short distance and make sure you have someone with you who can take over if you find you’re not quite ready.

Sleep and Energy Level

  • It is normal to have difficulty sleeping in the first 12 weeks from surgery.  Several ideas may help:

    • Find a comfortable position to sleep in.

    • Take pain medication 30 minutes before going to bed.

    • Ice for 30-45 minutes before going to bed.

    • Warm milk may help you relax.

    • If you do these and still have trouble sleeping, you may try taking Tylenol PM.  It’s okay to take 2 if needed.

  • It is normal to feel tired or fatigued for the first 12 weeks following surgery.  

    • This is because your body is expending a lot of energy trying to heal.  

    • Most patients find that they need to take a nap in the afternoon.  

    • If you feel tired, you should rest.


  • It is very important to get good nutrition following surgery.

  • You may not have much of an appetite for the first few weeks after surgery, but you should still make sure you are eating enough fruits, vegetables and protein.  

    • You need to provide your body with the building blocks it needs to heal.

  • We no longer recommend taking an iron supplement following surgery.  

    • Iron can increase your risk of post-operative constipation.  

  • Make sure you drink enough fluids, as the pain meds can be constipating. 


  • Constipation is not unusual following surgery.  It is a consequence of taking narcotic pain medications and having a reduced activity level.

  • To prevent constipation, make sure you drink enough fluids.

  • Add a fiber supplement to your diet—Benefiber, Metamucil, and FiberCon are options.

  • Eat berries, kiwi’s, dates, prunes and/or prune juice.

  • If you become constipated, add milk of magnesia to the above.  Take as directed.

  • Add a stool softener to your daily medications—Colace is over-the-counter.

  • If these are not effective, we recommend Miralax—over the counter bowel stimulant.

  • If you’ve tried all of the above and still are not able to have a bowel movement, get a bottle of magnesium citrate—also over-the-counter.  

    • Drink the whole bottle with 2 glasses of water.  

    • It should work within 3 hours.

  • If you’ve tried all of the above and have not successfully had a bowel movement, please call your PCP for additional options.

Bathing and Dressing Changes

  • Change your dressing daily starting on the second day after surgery and keep your wound covered for 2 weeks following surgery UNLESS you are specifically told to keep your dressing on longer (for example - PICO dressing). 

  • Once this initial dressing is removed, you can cover your wound with a simple gauze and tape dressing.  

  • You do not need to put Betadine or any other disinfectant ointment over the incision if you need to change your dressing.  

    • Use regular body soap.

  • You may shower as per your usual routine starting 2 days after surgery as long as your wound is not draining and there are no open spots.

    • You should remove the gauze and tape dressing prior to showering and replace it with a clean dry dressing after the shower.  

  • After approximately 14 days, you may leave the incision/wound uncovered as long as it is not draining or there are no open spots.  

    • At this point, you may shower without a bandage on the incision.  It’s okay to get the incision wet but do not scrub it.  Dab it dry when you are through.

    • If the wound is draining still or open, you should keep it covered and your surgeon should see the wound.

Bath, Jacuzzi, Swimming Pool

  • Do not immerse the incision in a bath, Jacuzzi, or swimming pool for 3 weeks following surgery.  

  • If you have any doubt about the extent of healing, please wait until you have come in for your post-operative appointment and we have evaluated the incision.  

When Do I Come to the Office for Check-Ups?

  • If you do not already have a post-operative appointment, please call the office at (808) 522-4232 and schedule an appointment for 2 weeks following surgery.  

  • This should be arranged by the nursing staff prior to leaving the hospital.  If you do not have a confirmed appointment on your discharge paperwork, please call for an appointment as soon as you get home.

  • If you are doing well at your post-operative visit, you will not need to return for further follow-up until the 6 week mark.  

    • After that, we will see you at 6 months and 2 years.

Post-Operative Cours

Additional Helpful Information

Who to Call for Medication Questions or Medical Concerns
  • For medication questions/adjustments or medical concerns, please contact your surgeon’s team or your PCP.  

    • Any questions regarding nausea, constipation, blood pressure issues or any other medical concern can be directed to your PCP as this is their area of expertise and you will be better served by them in these matters.   

  • Any post-operative concerns about pain, walking, exercises, physical therapy, or incision should be directed to your surgeon’s office.  

    • During the first 4 weeks, any concerns about temperature, redness, and heat around the incision should be directed to your surgeon’s office, as doctors unfamiliar with normal post-operative changes may misinterpret these as signs of infection.

  • You can reach your surgeon’s office at (808) 522-4232.  After hours, have the operator page the team member on call.

Medication Refills
  • If you need a pain medication refill in the first 4 weeks post-op, contact your surgeon’s office for refills.

  • Please be advised that it may take 24-48 hours to refill a prescription based on availability of staff/physicians - PLEASE PLAN ACCORDINGLY.

Antibiotics for Dental Work and Other Procedures
  • In general, you DO NOT need antibiotics for ROUTINE dental procedures - cleanings, fillings, etc. once you are 4 months after surgery.  

    • However, if you are not in great health or have diabetes, poor skin healing or any concerning health issues, we will provide you with prophylactic antibiotics for such procedures.

  • If you are going to have a MAJOR dental procedure (i.e root canal, surgery for infection/abscess, etc) it is generally recommended to take a pre-procedure antibiotic to minimize the chances of getting an infection that can spread from one area to another through the blood stream. 

  • Please do not schedule any routine dental work (including dental cleanings) for at least 4 months following surgery.  

  • Dental work prior to surgery is okay as long as it is completed at least 1 month before your surgery.

  • If you need antibiotics for any MAJOR dental work, we can prescribe or your dentist can prescribe antibiotics as follows:

    • AMOXICILLIN 500 milligrams - 4 tablets orally one hour prior to dental appointment


    • CLINDAMYCIN 300 milligrams - 2 tablets orally one hour prior to dental appointment

  • You do not need to take antibiotics prior to pedicures, pap smears, cataract surgery, routine colonoscopies or minor surgery to remove skin tags or biopsies.  You do not need to take antibiotics if your gums bleed with brushing or if you get a cut or scratch.

  • If you have any questions about whether or not you need antibiotics, feel free to call our office at (808) 522-4232.

Flying Following Surgery
  • Flying for vacation is not recommended for 6 weeks following surgery.  

  • If you must fly to return home, you may do so after discharge from the hospital.

  • Following are your recommendations with respect to flying:

    • Get an aisle seat so you can get up and walk on the plane every hour.

    • Wear compression socks on the flight(s)

    • Take a FULL STRENGTH ASPIRIN (or blood thinning medication) the morning of the flight(s)

    • Spell out the alphabet in the air with each foot every hour (this is tedious and time consuming, but it keeps the blood flowing)

    • Elevate your legs while sitting if you have enough space.

    • If it’s a long flight, take a Ziploc bag with you and have the flight attendant fill it with ice so you can ice your knee while you sit.

Flu and Other Vaccines
  • It is okay to have a flu vaccine or any other vaccination any time before or after surgery.

Massage / Acupuncture
  • Massage and acupuncture are fine any time following surgery.


    • Your wound must be completely healed. ​

Intimacy Following Surgery
  • Sexual activity following surgery is okay to resume as your comfort allows.  

  • There are no restrictions you need to be aware of other than to keep your wound clean and dry. 

Additional Information

Form Requests

State Disability
  • In general, patients undergo total knee replacement to restore function and to be able to go back to gainful employment, even heavy labor.


  • If you have an occupation that requires disability because of your knee replacement, this should be TEMPORARY disability and usually does not extend beyond THREE MONTHS UNLESS you have a catastrophic complication.  

  • If you plan on filing for disability after surgery, please discuss this with your surgeon PRIOR to surgery.

  • Please be aware, that if you plan to be on PERMANENT disability, your surgeon will refer you to get a “Functional Capacity Evaluation” by a certified occupational physician.

    • Such physicians will test your ability to carry out the functions of your job and this can generally be done at about 3-6 months from your knee replacement.

  • If you will be filing for TEMPORARY state disability, you need to go to THE HAWAII STATE DISABILITY SITE HERE and follow the instructions based on your situation.  

  • With regards to any forms, once you have completed your portion, call your surgeon’s office at (808) 522-4232 and let us know; we will complete the physician’s section.

    • Please be aware that these may take several days to prepare.

DMV Placards

  • Generally, knee replacement patients do not have a medical necessity for a DMV “handicapped” placard. 

  • Knee replacement surgery is done to restore your function and allow you to walk distances greater than that encountered in a typical parking lot/structure.  

  • Your surgeon’s office can authorize TEMPORARY parking placards for patients AFTER SURGERY.

    • These are available upon request and are valid for at most 3 months following surgery.  

    • The paperwork for the placard is online HERE 

  • Fill out your section, then deliver it to our office (in person, mail or fax).  

    • We will fill out the doctor’s section and have you pick it up or mail it to you (the signature has to be original).

    • Once you receive it, take it to the DMV to have the placard issued.  

  • Please note: It is against our office policy to extend your placard beyond 3 months.  

    • Once you are past the initial healing period for surgery (12 weeks), it is in your best interest to walk in order to build strength and endurance.  

    • Extending your placard goes against our practice philosophy.  Please do not ask for an extension unless you have rare extenuating circumstances (infection, complication, etc).

Jury Duty

  • If you need an excuse for jury duty, you must provide our office with your jury summons which includes a section for the doctor to fill out to temporarily excuse you.  As above, please allow several days for completion.

  • We expect you to be able to meet the physical demands to serve jury duty by approximately 3 months from your surgery.

Additional Form Requests

  • Please contact our office at (808) 522-4232 if you need to request letters from the doctor or if you need additional forms filled out.  

Form Requests

Important Contact Information

Phone Numbers / Contact
  • Should you have questions not addressed in this packet, please feel free to contact your surgeon’s staff at (808) 522-4232.

  • Our fax number is (808) 522-4401 should you need to fax us any paperwork/documents.

  • Alternatively, you may send us an e-mail through “MyChart”.  

    • You can access the system HERE

  • If you need to speak to your surgeon’s team after regular business hours, please di-al (808) 522-4000 and have the operator page the team member on-call. Your surgeon or one of his partners is on-call, nights, and weekends — 7 days/week.  

  • For the Hospitalist service – call (808)-522-4000.

  • For any billing questions, please contact the billing office by calling (808) 522-4000 and ask for the billing department.


All surgical procedures carry inherent risks that patients should be aware of prior to making the decision to undergo surgery.  In joint replacement, these risks include but are not limited to medical problems, anesthetic complications, blood clots, bleeding, infection, nerve/vessel/bone injury/fracture, stiffness, implant failure, need for revision surgery, and persistent pain.  Although every precaution is taken to minimize complications, the risks cannot be eliminated completely. 

Nationally, the complication rate from joint replacement is less than 5%.  With our protocols and attention to detail, we expect this percentage to be lower in our patient population.  Below is an outline of the risks and how we address them.

Medical Complications
  • Medical complications can include but are not limited to heart attack, stroke, kidney failure, respiratory complications, metabolic complications, or gastrointestinal complications.

    • All patients are required to obtain a medical clearance prior to surgery.  Our requirements for clearance include a thorough history and physical exam, blood work assessing your blood count and organ function, a urine test, a chest x-ray, and an EKG.  Any patient with a significant medical problem will also be asked to see a specialist.  For example, a patient with a history of heart attack, stent placement, bypass surgery, prosthetic heart valve, or rhythm problem (with or without a pacemaker) may be asked to see a cardiologist for clearance.  In some cases, a cardiologist may order a stress test prior to surgery.

    • Postoperative medications are modified based on patients’ medical health.  For example, if a patient has a history kidney failure, we will avoid medications that are filtered by the kidneys. 

    • We always have a nurse practitioner and hospitalist team follow our patients along with us during the hospital stay.  All our patients are seen daily by the hospitalist team to ensure that their underlying medical problems are being addressed and to quickly and skillfully address any complications that may arise.

    • Despite these precautions, medical complications are still possible.

Anesthetic Complications
  • Anesthetic complications can vary depending on the type of anesthetic used.  Our select group of anesthesiologists are very skilled and always choose the anesthetic that they feel will be safest given a patient’s medical history.  Please discuss any anesthetic concerns you may have with your anesthesiologist prior to surgery.

Blood Clots (also known as Deep Vein Thromboses, or DVT’s)


The presence of a clot in the leg can lead to an increase in swelling of the calf or thigh, and increased pain.  While swelling in the leg is normal after surgery, a dramatic increase in swelling associated with cramping calf pain and warmth or redness in the calf can be a sign of a blood clot. It is possible for a blood clot to progress to the lungs (pulmonary embolus).  

  • Early mobilization—patients start therapy exercises the day of surgery.  If surgery is in the evening, patients are assisted out of bed by a nurse.  The sooner patients start walking, the better the blood flows.

  • Every patient is put on a medication to help keep the blood thin.  Most patients are given Ecotrin (coated aspirin).  This is continued for 4 weeks after surgery.  If patients cannot tolerate aspirin or are already on a blood thinner for underlying medical problems, the blood thinning medication prescribed will be modified.

  • While in the hospital, all patients wear sequential compression devices (SCD’s) that wrap around the calves and periodically squeeze to help blood return to the heart. 

  • The highest risk period for developing a clot is the first 48 hours from surgery.  

  • In order to minimize bleeding intra-operatively, your surgeon operates under conditions of low normotensive anesthesia.  This means the anesthesiologist keeps your blood pressure low to minimize blood loss.

  • Electrocautery is used to stop any bleeding from small vessels encountered during the procedure.

  • Larger vessels that cross the surgical site are tied off with sutures and then cauterized.

  • Many patients receive a special medication called tranexamic acid to help prevent bleeding from the fragile vessels in the 24 hour period following surgery.  The patients who do not receive this medication are those who are on certain medications prior to surgery, those who have had a blood clot in the past, or those who have certain heart conditions.

  • Aggressive icing and elevating of the operative leg are encouraged in the several weeks following surgery so that post-operative swelling subsides.  If a leg remains very swollen, this can cause fluid and blood to seep out through the incision in the days after surgery.  Inflammation control with ice and elevation is very important in order for this bleeding to resolve.

  • All patients are given IV antibiotics in the pre-op area which will be continued generally for the first 24 hours.  They are not medically indicated after 24 hours unless a patient is very high risk for infection.

  • The operating team (surgeon, assistants, and scrub tech) all wear special sterile “space suits”.  In a non-joint replacement procedure, the team wears only a sterile gown/gloves.

  • Following surgery, we try to avoid close proximity with patients admitted to the hospital for medical and/or infectious reasons.

  • To prevent infection from occurring in the future, you will be asked not to have dental work or a colonoscopy performed for 4 months following your joint replacement.  Once you commence having dental cleanings and/or colonoscopy, you may need to take a dose of antibiotics 1 hour prior to your appointment depending on the procedure so that any bacteria that enters the blood steam will not be able to travel to your prosthetic joint.  


Nerve / Vessel / Bone Injury


  • There is a small skin nerve that in some people runs across the incision site and may be cut at the time of surgery.  This can result in an area of sensory numbness just to the outside of the incision. While sensation often returns over the course of a year following surgery, in rare cases, the numbness persists.

  • The orthopedic scientific literature has described rare cases of foot drop following knee replacement surgery.  This is an exceedingly rare complication. 

  • Fracture and/or bone injury are also very rare.  When fractures do occur, they are usually minor and do not require special treatment.  If treatment is necessary, it can generally be addressed at the time of surgery.  More significant fractures requiring additional surgery are possible but very rare.  

  • Ankle fractures have also been described in the literature but, once again, occur very rarely.

Stiffness following Surgery

Stiffness of the knee following knee replacement is normal in the first 8-12 weeks.  Motion during this period tends to be limited by post-operative inflammatory swelling.  As your swelling subsides, your motion should improve. For total knee patients, we expect that you will have approximately 80-90 degrees of flexion (bend) by 4 weeks post-operatively.  Most partial knee patients gain near full flexion.


The rest of your motion will be gained mostly in the following 8 weeks and more slowly over the course of the first year after your knee replacement. Rarely, rapidly forming scar tissue can hinder progress to full range of motion (described as -3 to 120 degrees).


  • You will work with a physical therapist twice daily while you’re in the hospital.

  • You will be given a list of exercises to do twice daily once you get home.  Only do them twice daily as too much can increase your swelling and hinder your progress.

  • You will be prescribed outpatient therapy in addition to the hospital exercises.

  • You may be provided with a continuous passive motion (CPM) machine to help gently enhance your motion in the first 3 weeks.  Only use the machine one hour once a day as, again, doing too much will hinder your progress.  Only advance the machine as your comfort allows.

  • If you have difficulty reaching 90 degrees by 8-12 weeks post-operatively, a manipulation under anesthesia may be recommended.  This is a procedure during which you go back to the operating room, are anesthetized, and your surgeon bends your knee to stretch/break the scar tissue that is preventing additional motion.  It is a very short and very effective procedure that less than 5% of our knee replacement patients will need.  

  • Rarely, stiffness may persist despite all the interventions listed.  

Implant Failure


  • The implants selected by your surgeon are carefully chosen based on long successful track records.  

  • However, any mechanical prosthetic device has the potential to fail. In this case, additional surgery could be necessary.



Continued Pain

  • Knee replacement patients can expect a significant reduction of pain originating from arthritis of the joint.  While the pain may not always resolve completely, most patients are able to return to the activities they enjoy and improve their quality of life.

  • Very rarely, pain can persist which cannot be explained and does not resolve.  

Need for Revision Surgery

  • Revision surgery may be necessary for multiple reasons including but not limited to implant failure, fracture, persistent pain, and infection.  Revision surgery for any of these reasons is typically rare, but nonetheless possible.  

“Clicking” Following Surgery

  • “Clicking” in a knee replacement is not a complication of surgery or a sign of failure.  

  • A knee replacement is not expected to behave like your native knee. 

  • Because the components are made of metal and plastic, as the knee moves through a range of motion, the components come into contact with each other making a “clicking” sound. 

  • This is nothing to worry about and tends to subside over the course of the first year following surgery.

  • In some cases it may persist, but will become less noticeable with time.

Risks of Knee Replacement

Knee Replacement Post-Operative Physical Therapy Protocol

All of your surgeon’s patients will go home with a copy of the exercises taught in the hospital and will be asked to do their exercises twice a day.  They will also be asked to take a short walk.  With respect to formal physical therapy, there are several possibilities; the final decision will be made on the day of discharge and will depend on a patient’s inpatient progress.  


If the patient is motivated and progressing quickly, the patient may go home within 24 hours of surgery.  If these patients are motivated, they may simply do their exercises twice a day and take a walk as stated above.  Formal therapy may not be necessary.


This option applies to patients who are doing well with ambulation and pain, are ready to go home within 24-48 hours of surgery, who would like formal guidance or possibly some extra motivation.  In this scenario, your surgeon will have you wait approximately 2 weeks from your surgical date to start “formal therapy.”  This is to allow time for the swelling to decrease and the wound to heal.  While in the hospital, we will help arrange this for you.  If it is not arranged by discharge, we ask the patients to let us know the name and fax number of the facility that is most convenient for them, and your surgeon’s office will fax the prescription directly to the facility.  Please be aware it may take a couple of days to get this set up.  Delaying formal therapy for a few days will not affect your surgical outcome, as you will still be expected to do your hospital exercises and take your walk in the interim.


This option is reserved for patients who are slower to progress in the hospital and need additional guidance at home.  A home therapist can be arranged by the case managers on the orthopedic floor. The therapists will see the patients at home 2-3 days a week for about 3 weeks.  Please be aware that once a referral is made, it may take a few days to start therapy as the home health agency needs to process the referral and obtain authorization from insurance.  Again, do your exercises twice a day, and you will do well.


On RARE occasion, patients need additional intensive physical therapy before they can safely navigate their home and are referred to a short-term rehabilitation facility.  If this is the case, the arrangements for the facility and the transfer will be made by the case managers on the orthopedic floor.  Please note, referrals to rehab are based on medical and physical necessity and NOT convenience.

PT Protocol

Knee Replacement Exercises


Post-op Exercises

Knee Replacement Discharge Instructions


  1. FOLLOW-UP - Follow-up with at 2 weeks from your surgery date.  This should be scheduled prior to leaving the hospital.  If you do not have an appointment arranged or you have any questions regarding the date and time of your follow-up appointment, please call the office at 808-522-4232.

  2. WOUND CARE - Depends on dressing applied at surgery. 

    • For gauze and tape - Starting two days after surgery, shower DAILY and wash your wound with soap and water every day at least once.  Do not scrub it with a brush or anything abrasive.  Let the skin glue (Dermabond) fall off on its own.  At the end of your shower, wash your wound one last time so it is the cleanest part of your body upon exiting the shower.  Immediately upon exiting the shower, pad your wound dry with a CLEAN towel (DO NOT RE-USE TOWELS FOR A MINIMUM OF 2 WEEKS AFTER SURGERY).  Immediately dress the wound as instructed once it is dry.  

    • For negative pressure wound therapy (PICO Dressing) - Leave in place for 7 days.  Ensure that the "OK" light is blinking green.  If an "error" light (orange light) is blinking or lit, please contact the office for further instructions.  If the office is closed, you can leave the dressing in place with an "error" light for 24-48 hours without a problem.  If the dressing is saturated, it can be removed and replaced with gauze or a new PICO that is provided.  Follow the instructions HERE for further PICO instructions.

  3. Do not submerge your operative knee in the bathtub, a pool, the ocean or in anything until instructed that this is OK.  You may go into a pool or jacuzzi when your incision is completely healed (“scabs” are no longer present and the wound is dry with no drainage) – usually about 3 weeks following surgery.

  4. If you develop a fever above 101.5°, have night sweats, shakes or chills, or the wound develops spreading redness or begins to have drainage, call the office immediately.  If it is the weekend, you should call the on-call physician through the Bone & Jone Joint Center - 808-522-4232.

  5. MEDICATIONS - Take one Aspirin (Ecotrin) once a day after meals for 4 weeks following surgery to prevent blood clots.  If on an alternative blood thinner, take as directed.

  6. Take milk of magnesia and/or a laxative of your choice if you become constipated (a common side effect of pain medications). Drink 6-8 glasses of water daily, increase your fruit and vegetable intake (apples, kiwis and berries are especially helpful), increase your fiber intake (eat oatmeal, brown rice, whole grain bread, prunes, fiber-con or Metamucil), and increase your activity to help avoid constipation.

  7. ACTIVITY - Do the instructed home exercises HERE at least TWICE PER DAY even on days you do therapy.  This works best by doing them in the morning and in the evening.  Take at least one walk a day.  

  8. When not walking, keep your leg iced and elevated to prevent/reduce swelling. Make sure your ankle is higher than your knee, and your knee is higher than your hip.

  9. Bruising behind the thigh and/or lower leg is normal following joint replacement surgery. Please do not be alarmed by this. It will be at its worst 2 weeks after surgery and it will then resolve on its own.

  10. To help with pain control and inflammation, use cold therapy as frequently as you can.  At a minimum, ice 30 minutes, 4 times a day (mainly after walking/standing).

  11. Use your joint within comfort level.  Do not "push" yourself for the first two weeks.  If your pain level or swelling increase significantly during activity, you should rest and ice until you are more comfortable.  Then resume activity as tolerated. 

  12. If you are going to do formal physical therapy, you should start this at approximately 2 weeks from your surgery.

  13. You may put your entire weight on your new joint unless  tells you otherwise. Use a walker initially. You may progress to a cane and independent walking as you feel comfortable.

  14. You may resume walking for exercise as soon as you feel comfortable doing so.

  15. You may resume driving when you feel safe doing so and you are no longer taking pain medications – usually 2-3 weeks following your surgery.

  16. You may resume golf and/or tennis 12 weeks following surgery as your comfort allows.

  17. Avoid dental, urological, or gastrointestinal procedures for 4 months following surgery.

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