The first days after total knee replacement

• Diet may be clear liquids only


• Intravenous line in the arm for fluids and antibiotics


• Pain medication by injection, or intravenously or as tablets.


• Blood transfusion if necessary


• Activity as tolerated to include walking: (Full weight bearing if a cemented knee was used and toe touch or limited weight bearing if an uncemented knee was used).


• Breathing exercises

The second and third day you can expect:

• Exercise program initiated

The fourth day to one week you can expect:

• Progression of walking and exercises.


• Instruction on how to dress, get in and out of bed and utilize the bathroom safely.

After surgery, vital signs and sensation in the lower extremities are observed and checked by the nursing staff and documented for the physician. Antibiotics are administered according to the physicians preference to reduce the risk of infection.

The surgical incision is observed closely for:

• Excessive drainage


• Proper initial healing


• The need for changing of sterile dressings

The respiratory therapist is essential at this stage for:

• Instruction for coughing and deep breathing exercises to help prevent complications, such as congestion or pneumonia.

Instruction on how to use a bedside device to assist in deep breathing exercise called the Incentive Spirometer. This device along with deep breathing exercises are important to minimize the risk of lung complications after surgery by removing any excess secretions that may settle in the lungs while asleep during surgery.

Shortly after surgery the physical therapist addresses:

• Circulation - At this point in the recovery, early stage exercises are instructed by the acute care physical therapist such as moving the ankles up and down to promote circulation and prevent clots. These exercises are often called ankle or gastrocnemius pumps.


• Range of motion - In order to aide the rehabilitation process at this stage, the physical therapist will place the operated leg in a continuous passive motion (CPM) machine. This machine supports the leg while it slowly and gently bends and straightens the knee. This passive motion (motion performed by the machine not the patient) helps prevent stiffening and reduces postoperative scarring. It is not uncommon for this device to be started in the recovery room with the patient waking up from surgery finding their knee moving under the power of the CPM machine.


• Mild muscle strengthening exercises - Once swelling has been stabilized and there is progress in the range of motion of the knee, mild strengthening and additional range of motion exercises are taught by the physical therapist to promote muscle activity and decrease muscle loss, which can occur with inactivity.


• Gait training - The physical therapist helps get you walking, beginning with short distances using crutches or a walker. This not only promotes the ability to bend the knee and strength but is also important for endurance and stamina. It is critical not to take full weight through the leg if those were the instructions given

The occupational therapist is involved in evaluating and addressing how well the patient with the new knee replacement functions with activities of daily living. Issues such as how safely and independently the patient is able to dress, bathe, and care for his or herself following total knee replacement are evaluated.

Exercising the knee and leg muscles following surgery is extremely important to the success of the total knee replacement.

Exercises aim to quickly regain increasing motion in the knee following surgery, prevent muscle loss, which is inevitable after surgery, rebuild the muscle strength and prevent stiffness of the new knee joint.

It is important therefore, to carefully follow the rehabilitation instructions given by the physical therapists and doctors.

Standard exercises that are used for early postoperative knee replacement include:

Quadriceps Setting

This is a good beginning exercise as it not only initiates the needed muscle contraction but also is helpful in increasing extension of the knee. It is optimal for both legs as both legs will be in a weakened state postoperatively. Try to do this exercise several times every hour. However, the amount of discomfort will determine how many each individual can perform.

While lying in bed with legs straight and together and arms at the side.

• Tighten the quadriceps muscles while pushing the back of the knee downward into the bed.


• Hold this muscle contraction for four to five seconds, relax for a short period of time and repeat 10-20 times for each leg.

Terminal Knee Extension

This exercise also helps promote muscle activity and increases knee extension. This exercise is to be repeated 10-20 times.

While lying in bed place a pillow or towel rolled up into a bolster under the operated knee to position the knee joint at approximately 40 degrees from full extension.

• Tighten the quadriceps muscle and straighten the knee by lifting the heel off the bed.


• Hold this muscle contraction for 5-10 seconds, then to slowly lower the heel to the bed.

Heel Slides (Knee Flexion)

This exercise will promote muscle activity of the hamstrings as well as help increase the amount of knee flexion. The physical therapist will record the amount of flexion and extension for a daily report on the patient's progress to be reviewed by the physician.

While lying in bed on the back, keep legs straight and together and arms at the side.

• Slide the foot of the surgical limb toward the buttock to a point where a mild stretch is felt.


• Hold this position to a count of ten then slowly returns to the starting position.

Straight Leg Raising

This is another excellent exercise to promote strength to the quadriceps and the flexor muscles important in ambulating. Once the individual can perform 20 repetitions without any difficulty, gradual resistance at the ankle (such as the use of ankle weights) can be utilized to further strengthen the muscles. The amount of weight used should be increased in no more than one pound increments.

• Bend the uninvolved leg by raising the knee and keeping the foot flat on the bed. (This will help decrease or avoid unwanted strain on the low back region).


• While keeping the involved leg straight, raise the straightened leg about six to ten inches off the bed.


• Hold this position for 5-10 seconds, then lower the leg slowly to the bed and repeat 10-20 times.

Pillow Squeeze

This is a good exercise to help strengthen the hip adductors or groin muscles.

• Place a pillow between the knees (or slightly above the knee joint line if pressure at this area is uncomfortable).


• Next squeeze the pillow and hold for a count of ten.


• Relax for a short period of time and repeat this exercise 10-20 times.

Advice on Sitting

• Use a chair with arms, to assist in rising from a sit to stand position.


• Avoid sitting for period of time longer than one hour without getting up and walking for a brief duration. If sitting for an extended period of time is unavoidable, elevate the foot to avoid excessive swelling of the lower extremity.

Advice on walking

• Remember : If the new knee was an uncemented type, weight bearing may need to be restricted to toe-touch only for the first six weeks.

Advice on lifting

• Lifting should be restricted to loads of up to ten pounds only.

Advice on showering

• Showering is recommended over bathing.

Advice on exercising

• Do the exercises that were recommended initially after discharge from the hospital.


• Formal supervision from a physical therapist is recommended to ensure all exercises are done properly.

Advice on getting into a car and driving

• The first step in getting into a car should be just to simply sit at the edge of the seat, followed by pulling in the legs and then pivoting to face forward.


• Driving is usually not recommended until after the first six weeks. In some cases, and under the recommendation of the surgeon, some patients may be able to return to driving a car sooner if it is equipped with an automatic transmission. and if good leg muscle control is present.

• If there is unrelenting significant pain in the knee.


• If the surgical incision becomes warm, red, or appears to have an opening or drainage.


• If swelling persists/increases.


• If either of the calf regions become swollen and painful or tender to the touch.


• If you become generally warm and ill feeling.


• If chest pain or coughing develop without cause or reason.