Preparing for Total Knee Replacement (TKR)

On this page, you will find information on how to prepare for your Total Knee Replacement Surgery (TKR).

The Knee

The knee joint is the largest joint in the body. A healthy joint has cartilage at the ends of the bones that acts as a cushion. It allows the joints to move smoothly and painlessly.

Osteoarthritis

Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates. When these cartilages begin to breakdown or damaged, the underlying bones begin to rub together resulting in narrowing of the joint space. Bone spurs (abnormal bone growths) are a common feature of osteoarthritis.

Osteoarthritis symptoms often develop slowly and worsen over time.

TKR

Signs and symptoms of Knee Osteoarthritis

Pain
Stiffness
Difficulty climbing up and down the stairs
Swelling
Weakness
Unable to squat
Unable to walk long distance

Knee Replacement

Aim: To relieve the painful symptoms and improve your quality of life.

This can be done by resurfacing partial (unicompartmental) or total replacement of the affected knee with implants (prosthesis) which encourage better function and mobility.

Before the Surgery

Refer to Preparation for Orthopaedic Surgery information >

Pre-Operative Assessment

2 to 3 weeks prior to your surgery, you will be required to attend a Pre-Operative Assessment at the Pre-Admission Centre (SGH Block 3 Level 1). This assessment is to determine your fitness and to ensure you are safe for surgery.

The entire assessment will take 5-6 hours. The journey includes:

Financial counselling – estimated bill for surgery and hospital stay
Blood Tests
ECG (if indicated)
Chest and/or Knee X-ray (if indicated)
Anaesthesia Assessment
Patient Education session
Physiotherapy session
Orthopaedic Diagnostic Centre (ODC) – for knee measurement

Pre-Operative Bath and Shampoo

The hospital recommends that you use antiseptic wash to reduce the amount of germs on your body prior to surgery. This may also help to lower the risk of contamination of the surgical wound.

Apply the antiseptic body wash from head to toe. (see Fig. 3)
Leave the antiseptic body wash on and rinse off with plenty of water after the recommended contact time. (see Fig. 1 or 2)
Dry your body with a fresh clean and dry towel.
Put on a fresh set of clothes to minimise the risk of re-introducing germs onto clean skin.
Use the antiseptic body wash 1 day before and on the day of surgery.
Do not use the antiseptic body wash if you have a known allergy to the antiseptic agent.
Do not use hair conditioners, skin care products and other hair care products after shampooing because chemical reaction may block the action of the antiseptic agents.
Stop using the antiseptic body wash if you develop any signs of allergy, for example: Rash all over the body, swelling of lips, tongue, throat, face, palpitation or breathing difficulties.

Where to apply the antiseptic body wash?

Fasting Instructions

Fasting is essential prior to surgery. In the event you did not follow the instructions, the surgery will be rescheduled. No food or drinks (except plain water) after midnight or as instructed. Last drink allowed is 1 cup (200mls) of plain water 2 hours before your surgery.

You may receive the carbohydrate loading drink (Preload) which provide the required energy for your body to use during your procedure. Please follow the instructions below if you are given carbohydrate loading drink to enhance recovery.


Evening before surgery (Before bedtime) Pour 400mls of water into a cup/bottle. Add 1 sachet of carbohydrate powder, stirring continuously until the powder has dissolved.	2 hours before surgery (Before leaving home to SGH) Pour 200mls of water into a cup/bottle Add half a sachet of carbohydrate powder, stirring continuously until the powder has dissolved.

Medicine

Certain medications need to be stopped in preparation for the surgery. Please inform your doctor of all medications you are on, especially blood thinners or herbal medications.

Diet

Have a balanced diet, include food rich in Vitamin C, calcium, iron and fiber in the diet. Drink plenty of fluids and stay hydrated unless otherwise instructed.

Smoking

Smoking causes breathing problems and impedes the rate of healing. Try to decrease smoking or seek help to stop smoking.

Blood Sugar Level

It is important to manage your blood sugar level to reduce risk of infection and bleeding which can affect wound healing.

Others

Any recent infection involving the throat, lung, urinary tract or skin must be highlighted to the surgeon prior to surgery. Your surgery might have to be postponed.
Have a parent / legal guardian to give consent if you are below 21 years old.

One day before Surgery

A nurse from Same Day Admission (SDA) Centre will contact you 1 working day before your scheduled surgery date. You will be informed of the following:

Time to report to hospital and time of surgery. Please bring along your admission kit.
Instruction to fast before surgery.
Medications to consume before surgery.
Bring all CD / X-rays or any medical notes from doctors on the day of admission and hand them to the nurse.
Safekeeping of personal items and valuables in the hospital. Do avoid bringing valuables to hospital.

Day of Surgery

Please remove

make up
nail polish
jewellery

Bring along

dentures
spectacles
hearing aids

You would be given a gown to change to before going to the operating theatre. Please arrange for someone to accompany you home when you are discharged.

During the Surgery

Duration of Surgery

Approximately: 1 - 3 hours.

Risks of Surgery

Complications will be explained to you by your surgeon before surgery. You will be required to sign an informed consent prior to surgery. The potential risks are:

Infection
Stiffness
Nerve and blood vessels injury
Periprosthetic fractures
Loosening and wear of prosthesis
Deep Vein Thrombosis

Duration of Hospital Stay

Average: 3-5 days

Care after Surgery

Refer to Preparation for Orthopaedic Surgery information >

Orthopaedic Team

You will be cared for by a multidisciplinary team comprising of the Surgeon / Doctors / Advanced Practice Nurses/ Resident Nurses/ Nurses/ Physiotherapist/ Occupational Therapist / Medical Social Worker / Dietician/Speech Therapist

After the Surgery

After your surgery, you will be brought to the recovery room in the operating theatre to be monitored before returning to the ward. In the recovery room, the nurse will frequently monitor your vital signs (blood pressure, heart rate, respiration rate, temperature and pain level).

Your loved ones are advised to wait at the waiting area. Please be informed that the recovery time varies and may take up to several hours. You may be transferred to the same day discharge ward/ short stay ward/ general ward/high dependency unit / intensive care unit depending on your condition.

Breathing

There may be an oxygen tube in your nose, which would be removed when you are feeling better. You will be guided to do deep breathing and coughing exercises. You may be given a breathing device to expand your lungs and help get oxygen to your lungs. This is to reduce the risk of lung infection.

Circulation

It is important to perform simple circulatory movements/leg exercises to help your blood flow. You may be given a pair of anti-embolic stockings and sleeves (pneumatic pumps) wrapped around your legs to prevent deep vein thrombosis. Patients undergoing joint replacement surgery may receive medications (to be taken orally or via injection) to prevent deep vein thrombosis.

Pain Management

You may experience some pain after surgery. The degree of pain you may have will vary and differ for individual. Your nurse will ask you to rate your pain on a scale. The goal is to minimize the pain so that you can rest and exercise. Report to the nurses or doctors is pain is not relieved. Pain medications should be taken around the clock for best effect during acute phase and gradually decrease as pain reduces.

Food/Fluids

You will have fluids through intravenous at first. It will be stopped when you are eating and drinking well. Increasing food slowly may help to avoid nausea that can happen after anesthesia or with use of pain medicine.

Bladder /Bowel care

You may have a tube (catheter) to pass urine from your bladder. This catheter will be removed once you are ambulating. Anesthesia and pain medication can cause constipation. Drinking plenty of fluids, eating vegetables and fruits are important. A stool softener or laxative can help normal bowel function. Inform your doctor/ nurse if you are unable to open your bowels.

Activity

The aim of care after your surgery is to allow you to return to your daily activities. The team will advise you regarding the daily activities.

The goal of Physiotherapy is to:

Restore movement and strength of the operated knee
Aid in return to normal activity as soon as possible

The goal of Occupational Therapy is to:

Ensure independence in self care
Provide equipment recommendation and home safety advice

Walking Aids Required After Surgery

After surgery, the physiotherapists will guide you through the rehabilitation process including providing you with suitable walking aids. Please do not rush to purchase them. The physiotherapist will advise you on the appropriate walking aid you require after your surgery.

Fall Precautions

During your hospital stay, inform the nurses if you need assistance with toileting, taking a shower or need help to reach your personal belongings.

Swelling and pain management

Swelling following surgery is expected. You should apply cold compress to the affected area following each set of exercises. You can use cooling sprays or gel-pack and apply over the affected area for 20 minutes three times per day. You should check the integrity of your skin during this process. If you experience severe pain, numbness, discolouration or new bleeding, inform your nurse or doctor.

Wound Care

Your incision may be closed by adhesive stitches, surgical tape, staples or topical skin adhesive. The wound should be covered with adhesive bandages otherwise explained by your doctor or nurse. Upon discharge, our nurse will provide information to you on managing your wound.

Special Instructions

Elevate operated leg with pillow to reduce swelling especially after exercise. (Place pillow under calf only)
Do not place pillow underneath your knee
Install grab bars in bathroom
Sit on a chair when showering
Arrange toiletries within easy reach
Non-slip mat in bathroom if tiles are not rough

DO NOT…

Squat
Kneel
Apply heat on operated knee
High impact activities (Jumping, twisting, running) – May damage prosthesis
Perform deep massage

Discharge plans

Discharge planning starts the moment you decide for surgery. Do prepare your home environment prior to discharge. Some of you will be enrolled in the Enhanced Recovery after Surgery (ERAS) program, whereby a team will provide home visits.

What to expect

Full Recovery: 6-12 months
Bruise – May occur: Common (May last one to two weeks following surgery)
Scar
Swelling: Continue elevation and use of ice therapy: Seek medical attention if swelling does not subside
Numbness may occur, will take time to recover
Implant: Can last 10-15 years, some even up to 20 years or longer
Implant card will be given
Our team will give you a hotline no if you have any queries or concerns

When to seek further treatment

Seek urgent medical consultation at polyclinic/GP/specialist outpatient clinic during office hours OR SGH DEM after office hours if any of the following conditions occur:

Redness at operated knee
Discharges from the wound
Fever >38°C and above
Body chills/sweating
Increasing pain over surgical site
Discomfort that is not relieved by medicine, rest/ice therapy
Legs are cool to touch, dusky in color, numb, tingling or develop calf pain
Had a fall/injury to operated knee

Special Instructions Post Surgery

Continuous Passive Motion (CPM)

Use of CPM depends on your surgeon’s instructions. It allows knee flexion and extension and helps to limit excessive scar tissue adhesions that may hinder your recovery.