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1. Preparation

WHAT IS TOTAL KNEE REPLACEMENT?

The knee joint is made up of 3 bones, the thigh bone (femur), shin bone (tibia) and kneecap (patella). A total knee replacement is when the ends of the femur and tibia are replaced with metal and plastic. Depending on the condition, the kneecap may also need to be replaced.

Damaged bone of the knee joint is replaced with smooth, artificial implants called prostheses. The prostheses prevent the knee bones from rubbing together and also provide a smooth knee joint.

WHAT IS A UNICOMPARTMENTAL KNEE REPLACEMENT?

A unicompartmental knee replacement is a partial knee replacement involving replacement of one side of the knee. This is usually done when one part of the knee is affected by arthritis and the remaining parts of the knee are healthy with the cartilage in good condition. For this operation the length of stay in hospital is shorter and recovery time quicker.

The following information pertains to a Total Knee Replacement:

WHY IS IT DONE?

If you have difficulty walking, performing everyday activities or are experiencing ongoing knee pain that persists even after your doctor has exhausted all conventional treatment such as medication and exercise, your doctor may recommend a Total Knee Replacement.

The most common cause of ongoing knee pain is osteoarthritis of the knee joint or the result of normal wear and tear over a person’s lifetime. Chronic knee pain can also be caused by a previous injury to the joint, rheumatoid arthritis and other degenerative conditions.

This surgery not only decreases pain but also increases mobility allowing you the independence to perform most everyday activities like walking up stairs, shopping and gardening. Unfortunately, even the best modern knee joint replacements are not as durable or as good as a normal knee joint and therefore there may be some limitation of the activities you can perform with an artificial knee joint.

HOW DO I CHOOSE A SPECIALIST?

Your GP will be able to recommend and refer you to an orthopaedic surgeon. You may be happy to accept their advice and recommendation, or you may like to investigate your choices; either option is safe and valid.

You can access the Australian Orthopaedic Association via the website at www.aoa.org.au. This site is very informative and allows you to access the orthopaedic surgeons in your region.

To access a list of Orthopaedic Specialists who participate in HCF’s Medicover no gap arrangement:

1. Call HCF Member Services on 13 13 34
2. Visit one of HCF’s customer service branches
3. Access HCF’s website at www.hcf.com.au / members / find a health professional / find a doctor

Some other useful sites you can visit to help prepare you for surgery and guide you through your recovery phase are:
www.ori.org.au
www.zimmer.com.au

WHAT SHOULD I ASK MY SPECIALIST?

• Make sure you fully understand the procedure that is planned; do not be afraid to ask questions.
• It is your right to know all the relevant information and associated costs, as this is part of informed clinical and financial consent.
• Your doctor will ask you to sign a consent form. Do this once you have a satisfactory understanding of the procedure.
• Apart from what the procedure involves, there are many lifestyle questions you need to ask about:
  • Discuss your lifestyle so the surgeon can select appropriate prosthesis as there are some variations in the types of prostheses
  • What you can expect from an artificial joint and the limitations (when can you drive, how far can you walk, when can you resume sports, sexual activities etc)
  • Take a family member or friend with you to the consultation so they can record instructions as it is hard to remember everything when you are anxious (quite normal when discussing surgery)
  • For male patients it is important to let your surgeon know if you have any trouble passing urine or hesitancy or poor flow as you may have an enlarged prostate and these symptoms can be exacerbated whilst on bed rest.
  • Discuss donating your own blood several weeks pre operatively to be re transfused post surgery
  • Let doctor know if you have any skin lesions, sores, cuts, or a raised temperature as you will need to have these treated before surgery.
  • Follow up appointments – (before your initial appointment or between appointments, jot down any questions or concerns you may have so you won’t forget to ask them)
• Most medication should be continued as usual, but some may interfere with the surgery. Your doctor will inform you of the medication you should stop. As a guide, the following medication may require special instruction:
  • Blood thinners (Warfarin, heparin.),
  • Arthritis medication,
  • Aspirin (or any related products),
  • Insulin

Always remember to tell your doctor what medication you are taking and don’t forget to include any herbal remedies or alternative medicines as these too may have interactions and side effects.

WHERE IS IT DONE?

A Total Knee Replacement is done in a hospital with an average length of stay of 8 days.

HOW LONG IS THE PROCEDURE?

It normally takes between 1-4 hours for a Total Knee Replacement.

WHO IS INVOLVED?

• The Orthopaedic surgeon, your Specialist doctor, performs the operation
• There may be an assistant surgeon
• The Anaesthetist gives you sedation prior to and during the operation. The anaesthetist also manages your pain medication post operatively. So remember to discuss your pain relief options with your anaesthetist
• Nurses will care for you throughout your hospital stay
• Radiologist for x-rays
• Pathologist for blood tests
• Physiotherapist who assist you with mobilisation post surgery

HOW DO I PREPARE FOR A TOTAL KNEE REPLACEMENT?

Your doctor will probably ask you to cease taking any anti-inflammatory medication such as:

• Feldene
• Voltaren
• Naprosyn
• Mobic

You will be required to cease the medication 7 to 14 days prior to your surgery to ensure they are out of your bloodstream. To maximise your procedure and recovery phase there are some activities you can do in the weeks leading up to your surgery

• Exercises: deep breathing and coughing (especially if a smoker), foot and ankle, knee strengthening. Discuss these with a physiotherapist as it is important to also perform these post op
• If you are a smoker and cannot give up completely, try to avoid smoking in the weeks immediately prior to your operation to reduce the risk of post-operative complications such as chest infections
• Making your home safe: remove long cords that you could trip on, if you have rugs on the floor roll these up
• place a non slip mat in the shower and organise a high shower chair
• rent or buy a long handled grabber for picking up things whilst you can’t bend or squat
• organise a cleaner or family for a couple of weeks (no sweeping, mopping, vacuuming for several weeks)
• place commonly used items within arms reach, especially if limited home support.
• Prepare some meals and freeze them for days you are too tired to prepare a meal
• Check out grocery stores and chemists in your local area who will home deliver
• If you live alone arrange an alert signal with your neighbour / family in case of emergency (eg a blind not up by 9am for them to check on you)

Any infections should be treated and cleared up prior to surgery as infectious organisms anywhere in the body, including on the skin, can travel through the blood stream to the joint replacement and cause problems.

You will be notified of your fasting times prior to theatre. If surgery scheduled for the morning, fast from 12 midnight otherwise if surgery scheduled for the afternoon you are expected to fast 6 hours prior to admission time.

Your doctor will have his/her own specific preparation requirements. These instructions should be strictly followed.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

• Do not bring any valuables with you
• Leave all jewellery at home (wedding ring is acceptable)
• Bring only enough money for items such as newspapers and magazines
• Slippers or flat rubber soled shoes for walking in the hallways
• Loose fitting clothing for the trip home
• Make sure that you bring any medication that you would usually take during the day, under some circumstances you may still be able to take these
• Personal grooming items such as hairbrush, comb, toothbrush, deodorant etc.
• Undergarments and a robe

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. if your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Total Knee Replacement admissions for the financial year 06/07 are provided below:

Points to Note:

• Charges are based on HCF claims for a sample size of 897 overnight admissions with an average length of stay of 8.5 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare item 49518.
• As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).
• These charges are for comprehensive product only. Check the level of your benefit under your hospital product.

¹ These medical services are in-patient services only.

² The medical charges are based on averages and each episode of care is different, i.e.

you may not have all of these medical services, and/or you may also have other medical

services not indicated here e.g. diagnostic procedures. Therefore, the total average

medical service charge ($4,342) differs from the sum of the individual average charges

as shown.

³ Doctors who do not use the HCF no-gap arrangement have a higher average out of

pocket charge, as their charges are higher than those doctors who use the no-gap

arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the

average benefits plus the average out of pocket charge you pay will not equate to the

charge as shown in the table.

⁴ Doctors’ charges vary so always ask your doctor whether he/she will participate in

HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the

Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered

under the HCF Medicover No Gap arrangement will receive as full payment for

services provided. This also applies to unregistered providers should they charge within

the schedule of benefit listed. This arrangement ensures that our members incur no out of

pocket expense.

⁵ This percentage indicates the total coverage of hospital and medical services for all total

knee replacement admissions. The percentages shown for each type of medical service

are much higher as they are calculated for those services only and not the entire

admission, which includes all medical services and the hospital services. In an admission

you may have one medical service with an out of pocket expense, which then excludes

the whole admission from being fully covered. Hence the significant difference in

percentage for individual types of medical services as compared to the total admission

fully covered.

For your information, the average charges for claims paid for Total Knee Replacement Rehabilitation admissions for the financial year 06/07 are provided below:

Points to Note:

• Charges are based on HCF claims for a sample size of 161 overnight admissions with an average length of stay of 12.6 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation and hospital related services).
• As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation and hospital related services).
• These charges are for comprehensive product and family equivalent only. Check the level of your benefit under your hospital product.

¹ These medical services are in-patient services only.

² The medical charges are based on averages and each episode of care is different, i.e.

you may not have all of these medical services, and/or you may also have other medical

services not indicated here e.g. diagnostic procedures. Therefore, the total average

medical service charge ($720) differs from the sum of the individual average charges as

shown.

³ Doctors who do not use the HCF no-gap arrangement have a higher average out of

pocket charge, as their charges are higher than those doctors who use the no-gap

arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the

average benefits plus the average out of pocket charge you pay will not equate to the

charge as shown in the table.

⁴ Doctors’ charges vary so always ask your doctor whether he/she will participate in

HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the

Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered

under the HCF Medicover No Gap arrangement will receive as full payment for

services provided. This also applies to unregistered providers should they charge within

the schedule of benefit listed. This arrangement ensures that our members incur no out of

pocket expense.

⁵ This percentage indicates the total coverage of hospital and medical services for all total

knee replacement rehabilitation admissions. The percentages shown for each type of

medical service are much higher as they are calculated for those services only and not

the entire admission, which includes all medical services and the hospital services. In an

admission you may have one medical service with an out of pocket expense, which then

excludes the whole admission from being fully covered. Hence the significant difference

in percentage for individual types of medical services as compared to the total admission

fully covered.

2. Day of procedure

WHAT HAPPENS TO ME AT THE HOSPITAL?

When you arrive at the hospital, the admissions clerk will attend to the associated paperwork for your stay in hospital

On admission to the ward, the nurse will orientate you to your surroundings, ask your medical history, confirm your medications and will ask about any known allergies. The consent for the operation is attended by the surgeon.

The Anaesthetist will visit you. He /she may order you a pre-med (something to relax you prior to transfer to theatre) discuss your anaesthetic options as below, and also your pain management options for the post operative period. A small injection is also given to prevent blood clots

There are two types of anaesthetic that may be used.

• General – You are asleep throughout the procedure
• Spinal or Epidural block – Numbing below the waist, usually sedation is given with this procedure

WHAT CAN I EXPECT DURING A TOTAL KNEE REPLACEMENT?

Once in the operating room, you will be anaesthetised. Once the anaesthetic has taken affect, your knee will be scrubbed and the area will be sterilised using a special solution. The lower portion of your leg, including your foot, will then be placed at a 90 degree angle in a device that will hold it in place. A tourniquet is applied to the upper part of your leg to slow the blood flow during the surgery.

An incision about 30cm long will be made from above the knee to below, and tissue and muscle will be moved to expose the joint.

The tibia and femur are cut and the diseased knee joint removed. Further bone from the tibia and femur may be removed to ensure the prosthetic knee joint fits correctly. A special type of glue called bone cement is used to anchor the prosthetic knee to the femur and tibia. If required, the knee-cap will be replaced as well. The ligaments and muscles are then rearranged and a drainage tube is inserted into the wound. The incision is closed with either stitches or clips and covered with a dressing.

3. Aftercare

WHAT HAPPENS AFTER A TOTAL KNEE REPLACEMENT?

Following the surgery, you will wake up in the recovery room where you will be closely monitored by nursing staff who will check your vital signs and pain management on a continual basis until you are fully conscious.

On return to the ward you are given medication to thin your blood to help prevent clotting, TED stockings are applied and you will be encouraged to move your feet and bend your other leg as soon as possible as this also helps to reduce the risk of clots. Pain relief will be given through an epidural or PCA (Patient controlled analgesia). A CPM (Continuous Passive Movement) machine is sometimes attached to the affected knee encouraging bending.

On the second day after your surgery, you will normally be allowed to start eating a light diet. A physiotherapist will visit you daily and show you how to perform knee exercises, including straight leg raising. You shall gradually be flexing your knee aiming for >90 degree flexion. On the 3rd or 4th day the physio will assist you to mobilise, initially with a frame and gradually using a walking stick. It is advisable to ask for pain relief prior to the physio visits. Before discharge you shall be able to climb stairs. Occupational therapists will advise how things may be modified in your home to make daily life easier for you once you are discharged. These suggestions may include:

• Handrails at the stairs, bath and toilet
• Footstools
• Raised toilet seats
• Crutches and walking sticks
• Remove any loose floor coverings to prevent falls

The pain, swelling and stiffness in your knee will take time to ease and it may take up to three months before you are fully recovered. It is important that you keep your wound site clean and dry till the clips are removed. Panadol is adequate pain control on discharge. Continue with your physio exercises on discharge aiming for >90 degree flexion. When you have recovered fully from the operation you shall be pain free with a better range of movement allowing you to return to your normal activities.

Having an artificial joint in your body makes you susceptible to infection in the future. Ensure you always tell other doctors or dentists, as you may need to have preventative antibiotics if having other procedures attended.

Before discharge, you should be given specific advice about follow up appointments, and any self care necessary in the intervening weeks. Make sure you are clear on issues such as wound care, pain management, any changes to your medication, and how long before you are able to drive.

Sometimes your Specialist may refer you to Rehabilitation Unit for improved mobilisation and increased independence in self-care. This may occur as an inpatient. The average length of stay is 12 days for an inpatient. Rehabilitation involves care under a specialised team including a Rehabilitation Specialist, Rehabilitation Nurse, Physiotherapist and Occupational Therapist. This team works together to ensure you reach your goal with mobilisation and independence, enabling you to return to your normal activities of daily living.

1. Preparation

WHAT IS TOTAL KNEE REPLACEMENT?

The knee joint is made up of 3 bones, the thigh bone (femur), shin bone (tibia) and kneecap (patella). A total knee replacement is when the ends of the femur and tibia are replaced with metal and plastic. Depending on the condition, the kneecap may also need to be replaced.

Damaged bone of the knee joint is replaced with smooth, artificial implants called prostheses. The prostheses prevent the knee bones from rubbing together and also provide a smooth knee joint.

WHAT IS A UNICOMPARTMENTAL KNEE REPLACEMENT?

A unicompartmental knee replacement is a partial knee replacement involving replacement of one side of the knee. This is usually done when one part of the knee is affected by arthritis and the remaining parts of the knee are healthy with the cartilage in good condition. For this operation the length of stay in hospital is shorter and recovery time quicker.

The following information pertains to a Total Knee Replacement

WHY IS IT DONE?

If you have difficulty walking, performing everyday activities or are experiencing ongoing knee pain that persists even after your doctor has exhausted all conventional treatment such as medication and exercise, your doctor may recommend a Total Knee Replacement.

The most common cause of ongoing knee pain is osteoarthritis of the knee joint or the result of normal wear and tear over a person’s lifetime. Chronic knee pain can also be caused by a previous injury to the joint, rheumatoid arthritis and other degenerative conditions.

This surgery not only decreases pain but also increases mobility allowing you the independence to perform most everyday activities like walking up stairs, shopping and gardening. Unfortunately, even the best modern knee joint replacements are not as durable or as good as a normal knee joint and therefore there may be some limitation of the activities you can perform with an artificial knee joint.

HOW DO I CHOOSE A SPECIALIST?

Your GP will be able to recommend and refer you to an orthopaedic surgeon. You may be happy to accept their advice and recommendation, or you may like to investigate your choices; either option is safe and valid.

You can access the Australian Orthopaedic Association via the website at http://www.aoa.org.au/. This site is very informative and allows you to access the orthopaedic surgeons in your region.

To access a list of Orthopaedic Specialists who participate in HCF’s Medicover no gap arrangement:

1. Call HCF Member Services on 13 13 34
2. Visit one of HCF’s customer service branches
3. Access HCF’s website at www.hcf.com.au / members / find a health professional / find a doctor

Please note: Participation in HCF’s no gap initiatives is at the doctor’s discretion. HCF does not guarantee that every medical service provided by these doctors will be a no gap service. Some doctors who participate in the HCF Medicover Gap have chosen not to be listed on the HCF website. Patients are encouraged to confirm with their doctor whether they will support HCF’s no gap initiatives for their treatment.

Some other useful sites you can visit to help prepare you for surgery and guide you through your recovery phase are:
http://www.ori.org.au/
http://www.zimmer.com.au/

WHAT SHOULD I ASK MY SPECIALIST?

• Make sure you fully understand the procedure that is planned; do not be afraid to ask questions.
• It is your right to know all the relevant information and associated costs, as this is part of informed clinical and financial consent.
• Your doctor will ask you to sign a consent form. Do this once you have a satisfactory understanding of the procedure.
• Apart from what the procedure involves, there are many lifestyle questions you need to ask about:
  • Discuss your lifestyle so the surgeon can select appropriate prosthesis as there are some variations in the types of prostheses
  • What you can expect from an artificial joint and the limitations (when can you drive, how far can you walk, when can you resume sports, sexual activities etc)
  • Take a family member or friend with you to the consultation so they can record instructions as it is hard to remember everything when you are anxious (quite normal when discussing surgery)
  • For male patients it is important to let your surgeon know if you have any trouble passing urine or hesitancy or poor flow as you may have an enlarged prostate and these symptoms can be exacerbated whilst on bed rest.
  • Discuss donating your own blood several weeks pre operatively to be re transfused post surgery
  • Let doctor know if you have any skin lesions, sores, cuts, or a raised temperature as you will need to have these treated before surgery.
  • Follow up appointments – (before your initial appointment or between appointments, jot down any questions or concerns you may have so you won’t forget to ask them)
• Most medication should be continued as usual, but some may interfere with the surgery. Your doctor will inform you of the medication you should stop. As a guide, the following medication may require special instruction:
  • Blood thinners (Warfarin, heparin.),
  • Arthritis medication,
  • Aspirin (or any related products),
  • Insulin

Always remember to tell your doctor what medication you are taking and don’t forget to include any herbal remedies or alternative medicines as these too may have interactions and side effects.

WHERE IS IT DONE?

A Total Knee Replacement is done in a hospital with an average length of stay of 8 days.

HOW LONG IS THE PROCEDURE?

It normally takes between 1-4 hours for a Total Knee Replacement.

WHO IS INVOLVED?

• The Orthopaedic surgeon, your Specialist doctor, performs the operation
• There may be an assistant surgeon
• The Anaesthetist gives you sedation prior to and during the operation. The anaesthetist also manages your pain medication post operatively. So remember to discuss your pain relief options with your anaesthetist
• Nurses will care for you throughout your hospital stay
• Radiologist for x-rays
• Pathologist for blood tests
• Physiotherapist who assist you with mobilisation post surgery

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. If your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Total Knee Replacement admissions for the financial year 06/07 are provided below: