Rapid Recovery Program is an innovative program for pain management that Sydney Knee Specialists use in patients who undergo knee joint replacement surgery. The program has been developed following years of research by the surgeons and research staff at Sydney Knee Specialists as well as using the latest techniques from evidence-based scientific studies from around the world. This has led to the development of a multimodal plan for management of pain following knee replacement surgery and revolutionised the way that people recover from a knee replacement. There are multiple facets to the program which is detailed below.
Traditionally, knee replacement surgery has been viewed as a very painful procedure and because of this, recovery has been slow. This new approach aims at reducing both pain and swelling within the joint so as to allow for a faster recovery with minimal pain so that you can return to near normal function as early as possible. As you can imagine, however, pain is a very individualised problem and varies from patient to patient. Most patients however describe the recovery following knee replacement at Sydney Knee Specialists with the Rapid Recovery Program as being relatively free from pain or significant discomfort which allows you to get back onto their feet a lot sooner.
Pre-surgery Workup
The surgeons at Sydney Knee Specialists strongly believe that developing muscles prior to your operation not only accelerates the recovery as muscle strength has been optimised, but also educates you on how to perform these exercises following the operation. Seeing a physiotherapist prior to your surgery to work on strengthening weak muscle groups as well as improving the way you walk has significant benefit. We strongly recommend that all patients who are considering a knee replacement if possible ride an exercise bike on a daily basis for a minimum of 10-15 minutes a day. If you have problems with chronic low back pain, often a recumbent exercise bike relieves pressure on the lower lumbar spine and makes strengthening the muscles around the knee easier. Other exercises to consider include gym exercises under the direction of your physiotherapist or exercise physiologist, and water based exercises which reduce the impact around the knee joint. In addition, aiming to lose weight before surgery assists not only speed of recovery but also makes any anaesthetic safer.
Anaesthesia
Most patients who undergo knee replacement surgery at Sydney Knee Specialists have a specialist anaesthetist in knee surgery. For most patients, we recommend having a spinal anaesthetic where a small needle with local anaesthetic is injected in the lower lumbar spine. It is similar to an epidural anaesthetic which some females have during childbirth however the difference is only a small amount of local anaesthetic is used and there is no plastic tube that is inserted into this region. It is now recognised as one of the safest forms of anaesthesia for knee replacement surgery when compared to general anaesthetic. The major benefits include less risk of nausea and vomiting following the operation, less postoperative pain, and in fact a greater capacity to walk sooner. Some patients have concern that they don’t want to aware during the surgery so most people also have an intravenous sedation which makes them unaware of anything happening during the surgery. This form of anaesthesia has also been shown to reduce the risk of both bleeding and also reduce the risk of formation of blood clots.
Prior to your operation, the anaesthetist will also give you some tablets which aim to reduce postoperative pain and also to make you feel more relaxed. This is called the premedication. It reduces pain following the surgery so that as soon as the local anaesthetics have worn off, there is minimal pain around the knee.
Minimal Invasive Surgical Techniques
The surgeons at Sydney Knee Specialists specialise in reducing the amount of trauma to the knee by using methods that allow the knee replacement to be inserted in the least invasive way. This involves a combination of surgical techniques to reduce disruption to the soft tissues around the knee and lessen the postoperative pain, as well as using specialised instruments (minimally invasive surgical instruments) that also lessen trauma to the knee joint. In addition, the use of a thigh tourniquet which reduces bleeding is restricted to only 15 minutes on average and this reduces the amount of weakness that can occur in the quadriceps muscle.
At the time of surgery, your knee joint will be injected with a combination of local anaesthetics. This local anaesthetic is what is termed as a long acting local anaesthetic (Naropin) and lasts for anywhere between 12 and 16 hours in relieving pain around the joint.
In addition, other medications are injected at the same time which have been shown to dramatically reduce the pain for up to three months. At a recent randomised control trial performed by Sydney Knee Specialists the surgeons found that injection of a high dose corticosteroid reduced pain by approximately 17% that lasted for up to three months, compared to patients who did not get this injection. This trial was published in 2013 in the Journal of Arthroplasty and is now an established technique used by Sydney Knee Specialists.
Postoperative Bleeding
At the completion of your surgery, the surgeon will inject approximately 30mls of a new medication called tranexamic acid into the knee joint. The surgeons at Sydney Knee Specialists were one of the first practices to use this medication and have tested it extensively. It has been proven from studies performed in our practice that this medication not only reduces swelling and pain around the joint but also decreases the risk of you needing a blood transfusion. Blood transfusions are now considered extremely rare following this surgery as opposed to 15% of patients who were receiving blood transfusions before use of this medication. The most important benefit in the use this medication is that it has lessened the pain experiences following surgery as there is less swelling around the knee joint which often is one source of pain and difficulty with bending your knee.
Pain catheters
At the time of your surgery, a small plastic tube called a pain catheter will be inserted into the knee joint. This tiny tube which is no more than 2mm in diameter is used to give a further dose of local anaesthetic the next day following your surgery. The nurses will give this injection through the catheter on the ward. We have found that this also dramatically reduces any discomfort in the knee so that no significant pain is felt for the first 24-36 hours. We have found this technique to be very safe and reliable and tested in over 2,000 patients.
Pain Management Plan
You will be given a pain management plan that allows you to recover sooner and perform your rehabilitation. This new approach to pain management is called pre-emptive multimodal analgesia. The concept is that pain is stopped by taking pain tablets before it actually occurs and hence pain can never develop to a point where it becomes uncontrollable. There are multiple different tablets that you will be prescribed to take and this will be varied according to each patient’s individual needs and circumstances. For most patients, they will be on regular Panadol Osteo three times a day, an anti-inflammatory called Celebrex for anywhere between six weeks and three months, a nerve tablet (Lyrica) which reduces nerve pain, and also long acting pain tablets (eg Targin or Oxycontin) especially at night. Additional tablets can be taken if required.
What can I expect following knee replacement in terms of pain
Most patients who go through the rapid recovery program walk the same day as having their operation with a physiotherapist. They report minimal pain in the first 24-36 hours and often are surprised that they have relatively little or no pain at all around their knee. Most patients spend a minimum of 2-4 days in hospital recuperating and can return to their home and be independent in terms of activities of daily living. Prior to leaving hospital, you will be shown how to walk up and down stairs and you will be walking independently around the ward, caring for yourself and feel confident on how to perform your exercises at home. You will be educated on the importance of icing the knee up to 6-8 times a day and performing your exercises 6-8 times a day. Performing these exercises and icing your knee maintains strength around the joint and will allow you to recover even faster. The majority of patients commence outpatient physiotherapy and hydrotherapy two weeks following the surgery. This is allowed to commence once the surgical incision has healed.
By 3 months, most people can resume normal activities. By six months, most people report no significant pain or only minor pain around the joint. A knee replacement can take up to one year to completely recover.