NAVIO^◊ Robotics-assisted Surgical System

Meet the NAVIO^◊ Surgical System, a robotics-assisted knee surgery platform that adds an extra layer of pre-surgical planning and improved precision for partial and total knee replacement procedures.

NAVIO Robotics-assisted knee replacement surgery

Your knee replacement surgery is unique, based on your knee anatomy and the implant used. Designed to help ensure your knee replacement is positioned and aligned correctly, surgeons use the NAVIO Surgical System. Proper positioning of the implant is important because implant alignment is a crucial factor in determining how long your implant may last.^{1, 2}

Decades of innovation in knee replacement surgery

Surgical techniques have evolved considerably since the earliest knee implant procedures were performed in 1968. These procedures relied on manual guides, external pins and cutting jigs to remove damaged bone and place the prosthetic implant.

Eventually more advanced implant positioning techniques were introduced that used long rods drilled into the central canal of the femur (thigh bone). These rods provide an attachment point for surgical cutting guides. More recent improvements introduced CT (computerized tomography) scan/MRI image guidance to create an individualized computer-generated surgical plan for each patient.

The latest innovation is the NAVIO Surgical System, a robotics-assisted platform that uses CT-free technology for precise implant sizing and positioning without the need for rods. The NAVIO Surgical System can be used for either a partial or total knee replacement procedure.

NAVIO system benefits: accuracy, less exposure to CT radiation

The NAVIO system offers two important benefits for people undergoing a knee replacement procedure. First, it helps your surgeon create a highly individualized plan that is specific to the unique shape and motion of your knee. Traditional planning may require CT scans, a series of images similar to x-rays that shows cross-sections of your knee. While other robotic-assisted platforms require CT scans, the NAVIO system works without them, meaning you are not exposed to the potentially harmful radiation experienced with this type of imaging.

The second benefit is robotic assistance. This combination of advanced technology is designed to help your surgeon and may result in more accuracy, giving you better long-term outcomes.

The NAVIO system is used for both partial and total knee replacement, which are distinctly different procedures. Here's a bit more information on how the NAVIO system is used in these surgeries:

Partial knee replacement

In partial knee replacement, your supporting tissue and ligaments that help stabilize your knee are spared and only the damaged portion of the knee is replaced. This means that healthy cartilage and bone remain intact to help your knee joint move smoothly with the prosthetic implant. Patients with osteoarthritis in only one area of their knee may be candidates for partial knee replacement.

Patients who undergo partial knee replacement often report a 'more normal' feeling knee, less pain and quicker rehabilitation³.

Robotics-assisted planning and partial knee surgical procedure

Using the NAVIO system, your surgeon creates a 3D representation of the unique shapes and profiles of your knee without the need of a pre-operative CT scan.

Using all of this information your surgeon can then determine the correct size and position of the implant. Implant size and position is critical to knee alignment and stability.

Next, your surgeon uses robotic assistance of NAVIO to physically remove only the damaged bone, preparing the site for the prosthesis, before placing and adjusting your partial knee implant.

Total knee replacement

In total knee replacement, the entire knee joint is replaced with a prosthetic implant designed to replicate the shape, motion and stability of your natural knee joint. Total knee replacement is one of the most common procedures performed in all of medicine, with over 600,000 performed in the U.S. every year. Ninety percent of people who receive a total knee replacement experience a dramatic decrease in knee pain, and an improvement in their ability to perform daily activities.⁴

Robotics-assisted planning, and total knee surgery guidance

Just as in the partial knee procedure described above, your surgeon creates a 3D representation of the unique anatomy of your knee without the need of a pre-operative CT scan.

Your surgeon uses your knee anatomy information to determine the correct size and position of the implant, and creates a surgery plan unique to your anatomy.

Disclaimer

Individual results may vary. There are risks associated with any surgical procedure including NAVIO-enabled Knee Replacement. NAVIO is not for everyone. Children, pregnant women, patients who have mental or neuromuscular disorders that do not allow control of the knee joint, and morbidly obese patients and patients contraindicated for UKR, PFA and TKA should not undergo a NAVIO procedure. Consult your physician for details to determine if NAVIO is right for you.

NAVIO^◊ partial knee replacement surgery

For people suffering from knee pain caused by osteoarthritis, whose damage is limited to a single compartment or area of the knee, partial knee replacement may be an option because it preserves healthy bone and ligaments while replacing the damaged area.^{1, 2} The NAVIO^◊ Surgical System uses robotics-assisted technology to help tailor partial knee replacement procedures to the unique shape and motion of each patient's knee anatomy.

Robotics-assisted planning for better surgical outcome

While it may seem counterintuitive, replacing only part of a knee joint can be more challenging than replacing the entire joint. This is because partial knee replacement must achieve an exact balance between the new implant - made of metal and plastic components - and the remaining portions of your natural anatomy made of bone and cartilage. As a result, one of the primary challenges of all partial knee replacements is precisely positioning the implant for each unique patient. Even minor changes in an implant's size or placement can cause the knee to function poorly or result in early failure of the implant and the need for future surgery.

The NAVIO Surgical System addresses the challenge of partial knee replacement by using both computer and robotic assistance to accurately map the surface of your knee, align your implant to your anatomy, and physically remove the bone necessary to place your new implant.³ This added level of assistance is important because implant alignment is a crucial factor in determining how long the implant will last. ^{5, 6}

Robotic knee surgery without radiation

Other robotic knee replacement systems use computerized tomography, or CT, scans to help a surgeon visualize a patient's knee anatomy. While CT scans are effective at showing the layers of knee anatomy, they can expose the patient to potentially harmful radiation. In fact, a single CT scan is equivalent to the radiation exposure received in 48 chest X-rays.⁴

The NAVIO system eliminates the need for CT scans by using an advanced computer program (similar to GPS navigation on your phone) to collect anatomic and alignment information about your knee. Once captured, this information is used to build a precise, computer-rendered 3D model of your knee that your surgeon will use to plan your surgery.

NAVIO Robotics-assisted partial knee replacement surgery

After all of the information about your knee is gathered and your surgical plan is created, your surgeon will use a robotics-assisted surgical tool (the NAVIO handpiece) to physically remove the damaged surface of your bone so that your new implant fits properly. Using the same 3D model of your knee, the handpiece is able to differentiate between the damaged areas that need to be removed, and the healthy areas that will remain. The NAVIO handpiece uses a burr that removes damaged bone for your implant.

The NAVIO system doesn't replace your surgeon. Rather, it assists your surgeon by adding an extra layer of planning to the procedure.

Partial knee replacement with traditional techniques

By comparison, traditional surgical methods for partial knee replacement use mechanical cutting guides that help guide a saw blade as it removes the bone necessary to place the implant. The NAVIO Surgical System helps tailor your partial knee replacement procedure.

Disclaimer

Individual results may vary. There are risks associated with any surgical procedure including NAVIO-enabled Knee Replacement. NAVIO is not for everyone. Children, pregnant women, patients who have mental or neuromuscular disorders that do not allow control of the knee joint, morbidly obese patients, or any other patients contraindicated for UKR, PFA, or TKA should not undergo a NAVIO procedure. Consult your physician for details to determine if NAVIO is right for you.

Total knee replacement surgery with the NAVIO^◊ Surgical System

More than 600,000 total knee replacement procedures are performed each year in the U.S. and more than 90% of these patients experience a dramatic relief in knee pain and are better able to perform common activites.¹ The NAVIO^◊ Surgical System delivers robotics-assisted tools designed to help tailor your total knee replacement surgery to the unique shape and motion of your knee.

Robotics-assisted knee replacement planning with the NAVIO System

The total knee replacement procedure starts with your unique anatomy in mind. By the time your procedure is complete, the damaged bones and cartilage within your knee joint will be removed and replaced with new implant components. Each of these implant components must fit precisely and be aligned to your natural anatomy if they are to provide you with the best outcome possible. The challenge of aligning your implant and preparing your bones to accept it can be complex, invasive and time consuming because no two knee joints are exactly the same.

The NAVIO Surgical System is designed to help your surgeon not only plan your surgery based on your unique anatomy, but also position your total knee implant using a combination of computer and robotic assistance. The NAVIO procedure starts with an advanced computer system that gathers precise anatomic and alignment information about your joint that your surgeon will use to create your specific surgical plan.

This extra layer of data collection and planning is designed to help ensure your knee procedure is performed exactly as your surgeon intends and that your implant is positioned as accurately as possible for the best long-term outcome.

CT-free

Other robotic-assisted knee replacement systems use computerized tomography, or CT, scans to help a surgeon visualize a patient's knee anatomy. While CT scans are effective at showing the layers of knee anatomy, they can expose the patient to potentially harmful radiation. In fact, a single CT scan is equivalent to the radiation exposure received in 48 chest X-rays. ²

The NAVIO system eliminates the need for CT scans by using an advanced computer program to collect anatomic and alignment information about your knee. Once captured, this information is used to build a precise, computer-rendered 3D model of your knee that your surgeon will use to plan your surgery.

Total knee replacement surgery without rods

Another method that can be used to determine the anatomic alignment of your new implants uses long, metal devices called intramedullary (IM) rods that are drilled into the central canal of the bone to show the alignment of the knee in relation to the hip. These rods are then used to attach the cutting guides necessary to guide the surgeon's saw blade as it shapes the bones to accept the new implants.

Because the NAVIO system has already gathered the anatomic alignment information about your knee, it eliminates the need for IM rods. Instead, your surgeon will use the system's handheld robotics-assisted tool (the NAVIO handpiece) to accurately position the NAVIO-specific cut guides which are held in place with a few small pins instead of the IM rod. This process leaves the central canal of your bone untouched. Implant alignment is a crucial factor in determining how long the implant will last ^{3, 4}.

NAVIO brings robotics-assisted precision to total knee surgery

After removing the cutting guides, the prosthetic knee implants are implanted and your knee is checked to make sure it moves and is balanced correctly. It is important to understand that the NAVIO system doesn't replace your surgeon. The procedure remains in the skilled hands of your surgeon, with the NAVIO system providing extra layers of planning, accuracy and precision.

Disclaimer

Individual results may vary. There are risks associated with any surgical procedure including NAVIO-enabled Knee Replacement. NAVIO is not for everyone. Children, pregnant women, patients who have mental or neuromuscular disorders that do not allow control of the knee joint, and morbidly obese patients should not undergo a NAVIO procedure. Consult your physician for details to determine if NAVIO is right for you.

JOURNEY^◊ II XR

Rediscover your active life with the high performance

A New Chapter in Knee Implants

Recent advances in biomedical engineering software have opened a new chapter in high performance knee implants.

One remarkable breakthrough has been the creation of the JOURNEY^◊ II XR Active Knee System, which combines an implant designed to restore the stability and natural motion of the human knee with low-friction materials that may help extend the longevity of the implant itself.

While the longevity of a knee implant is heavily influenced by the materials used to make it, the natural feeling of the implant during physical activity is dependent upon the way the patient's muscles, ligaments and tendons are addressed during surgery and by the implant's shape within the body after surgery.

Every knee implant design is faced with two important challenges; how to recreate the normal swing-and-rotate motion of your natural knee, and how to restore stability to your joint after surgery.

For the first challenge, conventional knee implant designs have attempted to recreate the natural, fluid motion of the knee with either a rotating platform (a simple pivot point) within the implant or by requiring an angled alignment of the implant during surgery. Both of these options force the muscles around your knew joint to work harder as they adjust to the joint's new and unnatural shapes and movement patterns.

For the second challenge, most implants rely on design aspects within the plastic insert to provide the stability that is sacrificed after the anterior and posterior cruciate ligaments (ACL/PCL) within your joint are removed to accommodate the new implant.

JOURNEY II XR is Different

Fortunately, the JOURNEY II XR Knee Implant is different from most knee implants.

First, the JOURNEY II XR implant features an anatomically shaped femoral component and two plastic inserts designed to work together to reproduce the original internal shapes and forces of your natural knee as it goes through its full range of motion. This attention to anatomic detail means that the muscles and other soft tissues around your joint don't have to adjust to unfamiliar stresses and you may be able to return to a natural pattern of motion after surgery.

Second, the JOURNEY II XR uses a U-shaped tibial base plate that fits around your healthy ACL and PCL, allowing them to remain in place and function normally after surgery. In short, the function of these important ligaments doesn't have to be re-engineered because they were never removed.

Added Durability

The JOURNEY II XR implant addresses durability with VERILAST^◊ Technology, a combination of two wear reducing materials - the proprietary OXINIUM^◊ metal alloy and a highly cross-linked plastic insert - that were designed to address wear on both surfaces of the implant.

Because it is twice as hard as cobalt chrome, the most commonly used metal in knee implants, implants made with OXINIUM material have been shown in lab testing to reduce joint wear by more than 80% when compared to cobalt chromium components.¹

VERILAST Technology was designed to address "wear and tear," which is only one of several reasons why a knee implant may need to be replaced. Each patient should listen carefully when his or her orthopedic surgeon reviews other risks that can shorten the life of a new knee - such as infection, weight gain or high impact sports.

The results of laboratory wear simulation testing have not been proven to predict actual joint durability and performance in people. A reduction in wear alone may not result in improved joint durability and performance because other factors can affect joint durability and performance and cause medical conditions that may result in the need for additional surgery. These other factors were not studied as part of the testing.

Not all patients are candidates for the JOURNEY II XR Knee Implant. Discuss your condition and implant options with your surgeon.

Anatomy and function of the knee

What makes up your knee?

The knee joint is the point at which the femur bone of the thigh meets the tibia bone of the lower leg. All the components of the knee - bones, cartilage, synovial membrane, ligaments, tendons and muscles - must work together properly for the knee to move smoothly.

Cartilage is a protective cushioning that keeps the bones from rubbing against one another.

In a healthy knee, a thin, smooth tissue liner called the synovial membrane releases a fluid that lubricates the knee, reducing friction as the bones move.

Osteoarthritis of the knee

What is osteoarthritis?

Osteoarthritis of the knee is a condition commonly referred to as "wear and tear" arthritis.

Causes

Although the degenerative process may accelerate in persons with a previous knee injury, many cases of osteoarthritis occur when the knee simply wears out. Some experts believe there may be a genetic predisposition in people who develop osteoarthritis of the knee. Osteoarthritis of the knee is the most common cause for total knee replacement surgery.

Symptoms

The primary symptoms of osteoarthritis are pain in the knee, swelling and stiffening of the knee joint. In the early stages of osteoarthritis the pain may be mainly associated with activity. As the cartilage wears away and the bones of the joint rub against each other, pain can become more severe and constant, interfering with regular daily activities and disrupting sleep.

Treatment

In the early stages of osteoarthritis, treatment may involve several techniques. Behavioral and lifestyle changes including losing weight and changing routines to avoid painful situations can be very effective in relieving pain. Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium may also provide relief from pain. Cox-2 inhibitors are also effective in providing knee arthritis pain relief. Physical therapy may improve muscle strength and joint mobility, reducing the symptoms of osteoarthritis in the knee. Joint fluid therapy may lubricate the knee and reduce the pain and swelling of the joint. Partial or total knee replacement surgery may be necessary as the disease progresses and daily functioning becomes more impaired.

Rheumatoid arthritis of the knee

What is rheumatoid arthritis?

Rheumatoid arthritis is a form of inflammatory arthritis and an autoimmune disease. For reasons no one fully understands, in rheumatoid arthritis, the immune system - which is designed to protect our health by attacking foreign cells such as viruses and bacteria - instead attacks the body's own tissues, specifically the synovium, a thin membrane that lines the joints. As a result of the attack, fluid builds up in the joints, causing pain in the joints and inflammation that's systemic - meaning it can occur throughout the body.

Causes

The exact cause of rheumatoid arthritis is unknown. It's possible that a virus or bacteria may trigger the disease in people with a genetic predisposition to rheumatoid arthritis. Many doctors think rheumatoid arthritis is an autoimmune disease in which the tissue of the joint's lining is attacked by the body's immune system. It's also possible that rheumatoid arthritis is caused by severe stress. The onset of rheumatoid arthritis occurs most frequently in middle age and is more common among women.

Symptoms

The primary symptoms of rheumatoid arthritis are similar to osteoarthritis and include pain, swelling and the loss of motion. In addition, other symptoms may include loss of appetite, fever, energy loss, anemia, and rheumatoid nodules (lumps of tissue under the skin). People suffering with rheumatoid arthritis commonly have periods of exacerbation or "flare ups" where multiple joints may be painful and stiff.

Treatment

Treatment of rheumatoid arthritis may involve medications such as non-steroidal anti-inflammatory drugs (NSAIDs), aspirin and analgesics. Corticosteroids may be prescribed and are effective in decreasing the inflammation associated with rheumatoid arthritis. Side effects can occur with the use of corticosteroids, and close monitoring by a physician is essential. Researchers have made progress in the treatment of rheumatoid arthritis and newer prescription drugs are now available. If non-surgical measures fail, you and your surgeon may decide that total knee replacement is the best treatment option to relieve your pain and help you return to an improved functional level.

One form of arthritis in the knee joint occurs as a result of degeneration of the cartilage in your knee. Osteoarthritis is commonly referred to as "wear and tear" arthritis or degenerative arthritis, and is the most common cause for total knee replacement surgery. Due to osteoarthritis, the cartilage in the knee breaks down over time and the result is a severely damaged joint surface with bone rubbing on bone. This process may occur as a result of previous trauma to the joint, ligament instability, or abnormal stresses to the joint.

Rheumatoid arthritis is an inflammatory process that results in erosion of the articular cartilage and subsequent damage to the knee joint surface.

Listed below are several non-surgical, and surgical options to consider for treatment of the arthritic knee:

1. Lifestyle Modification
   

   losing weight, avoiding aggravating activities, modifying exercise to low impact activities only

2. Exercises
   

   specifically prescribed to improve strength and flexibility without exacerbating your pain

3. Anti-inflammatory Medications
   

   designed to decrease swelling in the joint and provide temporary pain relief

4. Corticosteroid Injection
   

   powerful anti-inflammatory agent injected directly into the joint

5. Joint Fluid Therapy
   

   a series of injections directly into your knee, designed to improve lubrication in the joint

6. Glucosamine/Chondroitin
   

   dietary supplement that may relieve arthritic pain

7. Bracing
   

   used to provide external stability to the knee joint

8. Arthroscopic Surgery
   

   minimally invasive procedure to remove debris or repair torn cartilage

9. Total Knee Replacement Surgery
   

   surgical procedure that replaces all three compartments of the knee.

When is knee replacement surgery recommended?

What is the right age for total knee surgery?

Your surgeon's recommendation for knee replacement is based mainly on your level of pain and disability; there are no absolute restrictions on age or weight. Most of the people who have knee replacement surgery are between the ages of 50 and 80. The procedure has a high success rate and is considered relatively safe and effective.¹ Women are more likely to undergo the procedure; in 2009, the rate of knee arthroplasty for female patients was 57 percent higher than for males².

How do I know when it's time to consider surgery?

There are several reasons why your doctor may recommend knee replacement surgery.

People who benefit from knee replacement surgery often have:

• Knee pain that limits everyday activities, such as walking or bending
• Knee pain that continues while resting, either day or night
• Stiffness in a knee that limits the ability to move or bend the leg
• Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

Total knee replacement surgery is considered when all other conservative measures have failed to provide successful intervention, and may be performed for the following reasons:

1. To relieve pain
2. To improve joint stability
3. To improve alignment and correct bone deformity
4. To maximize quality of life
5. To optimize activities of daily living

Total knee replacement surgery is a common procedure performed on more than 600,000 people worldwide each year. With recent advancements in surgical technique and implant design, patients have experienced dramatic improvement in knee pain, function, and quality of life. Furthermore, most patients can now expect their implants to last up to a decade or more, allowing for years of active, healthier, pain-free living.

This is a brief overview of the activities that typically occur on your surgery day:

1. You will be admitted to the hospital or surgery center.
2. Your vital signs, such as blood pressure and temperature, will be measured.
3. A clean hospital gown will be provided.
4. All jewelry, dentures, contact lenses, and nail polish must be removed.
5. An IV will be started to give you fluids and medication during and after the procedure.
6. Your knee will be scrubbed and shaved in preparation for surgery.
7. An anesthesia provider will discuss the type of anesthesia that will be used.
8. Your surgeon will confirm and initial the correct surgical site.

How is Knee Replacement Surgery Performed?

During knee replacement surgery, the surgeon surgically removes the damaged bone and cartilage of the joint and replaces it with smooth, artificial implants - thereby eliminating painful bone-on-bone contact.

Almost all knee replacement implants consist of a four-part system:

• The tibial (shin) side has two elements and replaces the top of the shin bone. This portion of the implant is made up of a metal tray attached directly to the bone and a plastic spacer that provides the lower half of the new joint's bearing surface.
• The femoral (thigh bone) side is a single element that replaces the bottom of the thigh bone and provides the top half of the new joint's bearing surface. This component also replaces the groove where the patella, or kneecap, sits.
• Finally, the patellar component replaces the surface of the kneecap, which rubs against the femur. The patella protects the joint, and the newly resurfaced patellar button will slide smoothly on the front of the joint

Important Safety Notes:

Knee replacement surgery is intended to relieve knee pain and improve knee functions. However, implants may not produce the same feel or function as your original knee. There are potential risks with knee replacement surgery such as loosening, fracture, dislocation, wear and infection that may result in the need for additional surgery. Longevity of implants depends on many factors, such as types of activities and weight. Do not perform high impact activities such as running and jumping unless your surgeon tells you the bone has healed and these activities are acceptable. Early device failure, breakage or loosening may occur if you do not follow your surgeon's limitations on activity level. Early failure can happen if you do not guard your knee joint from overloading due to activity level, failure to control body weight or accidents such as falls. Talk to your doctor to determine what treatment may be best for you.

After your surgery is completed, you will be transported to the recovery room for close observation of your vital signs, circulation, and sensation in your legs and feet. As soon as you awaken and your condition is stabilized, you will be transferred to your room. Below is an example of what you may see when you wake up:

1. You will find a large dressing applied to your incision in order to maintain cleanliness and absorb any fluid.

2. There may be a drain placed near your incision in order to record the amount of drainage being lost from the wound.

3. You may be wearing elastic hose, and/or a compression stocking sleeve designed to minimize the risks of blood clots.

4. Your doctor may prescribe a PCA (patient-controlled analgesia) that is connected to your IV. The unit is set to deliver a small, controlled flow of pain medication and is enacted when you firmly press the button on your machine. Press the button anytime you are having pain.

5. You may have a catheter inserted into your bladder as the side effects of anesthesia often make it difficult to urinate.

6. A continuous passive motion (CPM) unit may be placed on your leg to slowly and gently bend and straighten your knee. This device is important for quickly regaining your knee range of motion.

7. When your leg is not in the CPM, you may be wearing a knee immobilizer to protect your knee when you stand up.

Knee replacement complications

Although knee replacement surgery is often referred to as a "mainstream procedure," and is considered one of the most successful procedures in all of medicine¹, every surgical procedure comes with risk of complications. That's why it is important to dininescuss with your doctor and your orthopaedic surgeon the full balance of risks and benefits of knee replacement surgery, before you make your treatment decision. Remember, the information in this section is not intended to replace professional medical advice. If you have questions or concerns, turn to your doctor for answers.

Possible complications following surgery

According to the American Academy of Orthopaedic Surgeons (AAOS), the rate of serious complications following total knee replacement surgery, such as infection in the knee joint, is very low, under two percent.¹ If your health is already challenged by a chronic medical condition, the chance of complication can be greater. Uncommon as they are, if complications occur they can delay or limit your ability to recover fully from your surgery. These are some of the complications that can occur:

Blood clotting (thrombophlebitis)

Blood clots occur naturally and perform a vital role in the body's healing process to stop bleeding. However, blood clots can also form when blood stops flowing properly and pools in large veins, such as those in the legs. In a condition known as Deep Vein Thrombosis, blood clots formed in the veins can travel to the lungs where they lodge in the capillaries, causing a very serious blockage called pulmonary embolism. These are measures your care team may use to avoid blood clots:

• You may be prescribed blood-thinning medicines known as anticoagulants
• In the hospital and later at home, you may be instructed to wear elastic stockings (TED hose: the acronym stands for "thromboembolic disease") to help blood return from your lower leg veins to your circulatory system
• You may be assigned foot and ankle exercises for the same reason: to help increase blood flow and enhance venous return in the lower leg.²

IMPORTANT NOTE: Watch for signs of trouble, such as swelling, redness, pain and tenderness in your calf muscle. If any of these symptoms occur, report them to your orthopaedic surgeon or internist right away.

Infection

Even though doctors, nurses and technicians take great precautions before, during and after surgery to avoid infection, it can occur. If a significant infection should occur, additional surgery and/or the removal of the knee implant may be necessary.

Signs of infection can appear either before your release from the hospital, or later after you have returned home. Your care team may suggest these steps to minimize the chance of problems with infection:

• Monitor your incision closely and immediately report any redness, swelling, tenderness, increased drainage, foul odor, persistent fever above 100.4 degrees, or increasing pain
• Take your antibiotics as directed and don't stop until you finish the complete course, even if you're feeling better
• Ask for incision care instructions in writing, and follow them carefully and completely. As your incision heals, ask when it's OK to stop your incision care routine².

Pneumonia

Many people wake up from anesthesia feeling weak and sore, so they find it uncomfortable to breathe deeply. However, if you don't inhale and exhale fully, fluids could pool in your lungs, causing congestion or pneumonia. Your care team may take these steps to minimize the risk:

• Incentive spirometer: This is a simple device that shows you whether your breathing is deep enough to avoid congestion. Your nurse or respiratory therapist will demonstrate how to use your breath to lift and suspend balls in a plastic tube.
• Deep breathing exercises: Your nurse or respiratory therapist may have you place a hand on your belly, then inhale slowly and deeply through your nose as your belly expands. Next you will exhale through your mouth at a slow and controlled rate.

Long term pain

While the great majority of patients - nine out of ten, according to statistical studies¹ - experience steady reduction of pain after their procedure, a small number of people report that pain persists over a longer term after knee replacement surgery.

Knee stiffness

In some cases, the mobility of your knee following surgery may be significantly restricted and you may develop a contracture, or restriction in the joint, that causes stiffness during walking or other daily living activities. Your care team may prescribe steps or treatments to help you achieve maximum range of motion following surgery:

• A Continuous Passive Motion (CPM) unit to slowly and gently bend and straighten your knee. The object is to help you regain your greatest range of motion as quickly as possible
• Early physical therapy, starting on day one or two after surgery, including range of motion
• exercises and a supervised walking program
• Edema control to reduce swelling. Measures can include ice, compression stockings, and
• elevating your lower legs when you lie down or sit
• Adequate pain control so you can put maximum effort into your rehabilitation program

This rare complication is more likely in people whose range of motion was impaired before the procedure.

Implant wear or failure

The design of knee implants and the materials they're made from are improving all the time. It is possible, however, for the hinge surfaces to wear or deteriorate, and for other components to loosen. In rare cases another surgery might be needed to correct or replace the implant.

Fortunately, recent advances such as implants made with OXINIUM^◊ technology can help offset implant wear.

Nerve or vascular complications

It's uncommon, but possible, for nerves or blood vessels in the area around the knee to be damaged during surgery.

In order for you to meet the goals of knee replacement surgery, you must take ownership of the rehab process and work diligently on your own, as well as with your physical therapist, to achieve optimal clinical and functional results. The rehabilitation process following total knee replacement surgery can be quite painful at times. However, if you commit to following your program and overcome the challenges in rehab, you will succeed in meeting the goals you set when deciding on surgery. The following outline will summarize the process you will adhere to during rehabilitation:

1. In the Hospital
• CPM (continuous passive motion) beginning day one or two
• Ambulation with a walker or crutches (weight-bearing status determined by your surgeon)
• Range of motion exercises
• Edema control (ice, compression, elevation)
• Instruction in home exercise program
• Discharge goals are as follows:
1. Independent getting in and out of bed
2. Independent in walking with walker or crutches
3. Independent in walking up and down 3 steps
4. Independent in your home exercise program
5. Ability to bend your knee 90 degrees
6. Ability to fully straighten your knee
2. At Home
• Begin ambulation with a cane as tolerated.
• Continue CPM (if necessary) and range-of-motion exercises.
• Keep incision clean and dry; watch closely for signs of infection.
• Continue home exercise program.
3. Outpatient Physical Therapy
• Advanced strengthening program, adding weights as tolerated
• Stationary cycling
• Walking program
• Aquatic therapy program
4. Long-term Rehabilitation Goals
• Range of motion from 100-120 degrees of knee flexion
• Mild or no pain with walking or other low-impact physical activities
• Independent with all activities of daily living

(Consult your therapist regarding the number of reps)

Leg Lifts
Raise leg six inches above the mat, keeping knee straight.

Knee Extension
Place a pillow under your knee. Lift your foot off the mat.

Ankle Pumps
Flex ankle up and down.

Quadriceps Sets
Tighten thigh muscles and hold contraction for five seconds.

Heel Slides
Flex your hip and knee. Return knee to the straight position.