How can I have a better recovery after my total knee replacement (TKR)?

Total knee replacement (TKR) is a common surgical approach for treating degenerative and musculoskeletal disorders such as knee osteoarthritis (OA) or acute knee trauma.^1,2 However, many patients who undergo TKR experience prolonged pain and limitations with mobility related to the surgery.^3,4 On the basis of a systematic review of 11 studies on knee replacement, including 12,800 patients who underwent TKR, 10-34% of patients experience long-lasting pain related to TKR.³ Individuals should experience improvements in their pain and mobility within six to eight weeks postoperatively; however, some patients may not reach full capacity for daily activities until at least six months postoperatively, with 13% experiencing moderate to severe pain 12 months after TKR.⁵

While patients preparing to undergo TKR may experience some stress, preoperative stress can have lasting impacts on the recovery process and success of the surgery.^5,6 One prospective observational study evaluated 116 patients with OA at 1, 3, 6, and 12 months post-TKR to describe the course of pain and identify factors leading to prolonged pain after TKR.⁵ Half of these patients who underwent knee replacement reported that their pain was resolved within three months; however, about 13% reported moderate to severe pain after one year despite normal radiographic evidence and clinical criteria that their TKR was clinically successful. Individuals reporting higher levels of depression and anxiety preoperatively were more likely to experience prolonged pain ranked moderate to severe a year after the TKR was completed compared to those with lower levels of anxiety and depression before surgery.⁵

A qualitative study using focus groups with 22 patients described the most common stressors patients undergoing knee replacement face in the first few weeks after TKR. Some of the most common stressors were levels of pain, adequate pain management, physical therapy, and dependency on others, highlighting the need for preoperative education around these topics.⁷ Transitioning to post-operative care and rehabilitation was difficult for many patients undergoing knee replacement due to unrealistic postoperative expectations. These included the amount of time and effort required for recovery, lack of independence after surgery, and expectations about the time frame for returning to work or achieving certain fitness goals that were set preoperatively .^7-9 Strategies to control preoperative and postoperative stress may be effective in reducing pain and increasing mobility after knee replacement surgery.^5-7

Patients with higher self-efficacy, social support, and locus of control, or feelings of being in control over the outcomes of their life, demonstrated quicker recovery times and greater improvements in pain and mobility compared to patients who did not.^8,10-12 Patients undergoing knee replacement were not used to heavily depending on others for activities of daily living. This dependence on others was cited as a source of stress for knee replacement patients and is vital to their recovery from surgery. An analysis of 1,722 patients undergoing knee and hip replacement over the course of 24 months at four different hospitals measured the importance of social support in recovering from joint replacement surgery.¹³  The data indicated that those with stronger social support were discharged from the hospital sooner (2.7 days vs. 3.6 days, p<0.05), discharged to home more frequently (95.6% vs. 57.1%, p<0.0001), and were more confident in their ability to take control of their recovery after discharge (81.5% vs. 33.3%, p<0.0001) compared to patients with lower levels of social support.¹³ Self-efficacy and locus of control can be fostered in patients through relaxation and breathing techniques¹⁴ while social support can be achieved through relationships with family, friends, and professionals.^{5,7,8,10,13,15} 

Physical therapy and rehabilitation exercises are important for TKR recovery. Patients who challenge their selves to move their bodies shortly after surgery often experience better outcomes. One randomized control trial (n=44) compared a standard of care exercise program to an intense exercise and behavioral intervention program for patients after TKR. Individuals in the intervention arm experienced a greater improvement in pain level (−7.8 ± 6.1 vs. 5.4 ± 9.4, p=0.035), physical function (20.2 ± 17.7 vs. 6.8 ± 17.3, p=0.017), and single-leg stance (2.0 ± 4.2 vs. −1.9 ± 4.4, p=0.037) compared to patients in the standard of care arm.¹⁶ While rehabilitation is important for TKR recovery, it is often difficult for patients to adhere to rehabilitation exercises due to postoperative pain.^5,16,17 While pain management is an important factor in joint replacement surgery, pain medications should be tapered or returned to presurgical doses in patients with chronic pain within six weeks of surgery.^18-20 Patients who experience prolonged pain after TKR may adopt other pain management strategies, such as ice or heat therapy, and over-the-counter pain relievers under the guidance of their physician.^18,21

^References

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