1. Total Knee Arthroplasty Protocol Dr. D. N. Bid Sarvajanik College of Physiotherapy, Surat. 12/23/2012

2. Introduction TKA is one of the most successful and commonly performed orthopedic surgery. The best results for TKA at 10 15 yrs. compare to or surpass the best result of THA.

3. Indications for Knee Arthroplasty

4. Indications for TKA Relieve pain caused by osteoarthritis of the knee (the most common). Deformity in patients with variable levels of pain: Flexion contracture > 20 degrees. Severe varus or valgus laxity.

5. Osteoarthritis American College of Rheumatology classification criteria: Knee pain and radiographic osteophytes and at least 1 of the following 3 items: Age >50 years. Morning stiffness = 5 degrees. disease instead of ROM < 90 degrees. HTO. Angular deformity >= Elderly thin patient 15 degrees. with Cartilaginous erosion unicompartmental in the weight-bearing disease (shorter area of the opposite rehabilitation, greater compartment. ROM)

8. Patellar Resurfacing Indication for leaving the patella unresurfaced: Congruent patellofemoral tracking. Normal anatomical patellar shape. No evidence of crystalline or inflammatory arthropathy. Lighter patient.

9. Classification

10. Classification 1 31- Cruciate retaining2- Cruciate substituting3- Mobile bearing4- Unicondylar 2 4

11. Degrees of Freedom Constrained Prostheses Non-constrained Prostheses Intermediated Prostheses

12. Constrained Prostheses Hinged implants. One degree of freedom.

13. Non-constrained Prostheses Ideal implants. 5 degrees of freedom. Intact ligamentous system.

14. Intermediated Prostheses Anterior-posterior stability. Two types: FREEMAN (a cylinder in a non conforming trough). INSALL (posterior stabilized knee).

15. Intermediated Prostheses FreemanInsall

16. LongitudinalAlignment Of Knee Tibial components are implanted perpendicular to the mechanical axis. Femoral component is implanted in 5 6 degrees of valgus.

17. Longitudinal Alignment Of Knee Posterior tibial tilt is about 5 7 degrees. Usually depend on the articular design. Anatomic tilt 5 degrees

18. Rotational Alignment Of Knee Create a rectangular flexion space. External rotation of the femoral component 3 degrees.

19. Role of PCL Femoral Roll-Back

20. Role of PCL Femoral Roll-Back

21. PCL-retention or PCL-substitution ? PCL retaining PCL substituting prostheses: prostheses: Better ROM (roll-back, flat Easier surgical exposure. tibial surface). See-saw effect prevention. More symmetrical gait Lower tibial polyethylene (stair climbing). contact stress Less femoral bone Posterior tibial component resection is required. displacement. PCL needs to be accuracy Patella clunk syndrome. balanced.

22. PCL-retention or PCL-substitution ?

23. PCL-retention or PCL-substitution ?

24. Patellofemoral Joint Limb with larger Q angle has a greater tendency for lateral subluxation. Preventing subluxation: Prosthetic component. Vastus medialis (in early flexion).

25. Surgical Technique for Primary TKA

26. Preoperative Evaluation Soft tissue defects around the knee. Vascular status to the limb. Extensor mechanism. Preoperative range of motion. Standing (AP) view, a lateral view of the knee, and a skyline view of the patella.

27. Surgical Preparation Administer a dose of a 1st generation cephalosporin (or vancomycin, clindamyc in) Avoid pressure on peripheral nerves.

28. Surgical Approaches Medial parapatellar retinacular approach. Subvastus approach. Midvastus approach.

29. Varus Deformity 1st Osteophytes must be removed. 2nd Release the deep MCL. 3rd Release semimembranosus and pes anserinus insertion. 4th release posterior capsule and PCL.

30. Varus Deformity

31. Valgus Deformity 1st Remove all osteophytes. 2nd release lateral capsule. 3rd Lesser deformity: release Iliotibial band. Greater deformity: release LCL +/- PCL. Valgus deformity + flexion contracture >> release posterior capsule.

32. Valgus Deformity

33. Flexion Contracture Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule release. Flexion gap < Extension gap >> larger tibial insert.

34. Postoperative Management

35. Total knee replacement exercise protocol Outline Postoperative day 1 Bedside exercises (e.g. ankle pumps, quadriceps exercises) Postoperative day 2 Exercises for active ROM and terminal knee extension Gait training with assistive device Postoperative day 3-5 Progression of ambulation on level surfaces and stairs (if applicable) Postoperative day 5 to 4 weeks Stretching of quadriceps and hamstring muscles Progression of ambulation distance

36. Complications of Total Knee Arthroplasty Thromboembolism. Infection. Neurovascular complications. Patellofemoral complications. Periprosthetic fractures.

37. Brigham andWomens Hospital Protocol 12/23/2012

38. Brigham and Womens Hospital Protocol The intent of this physical therapy protocol is to provide the clinician with a guideline of the post- operative rehabilitation course of a patient who has undergone a total knee arthroplasty (TKA). It is by no means intended to be a substitute for ones clinical decision making regarding the progression of a patients post-operative course based on their physical exam/findings, individual progress, and/or the presence of post-operative complications. 12/23/2012

39. This physical therapy protocol applies to primary total knee arthroplasty. In a revision total knee arthroplasty, or in cases where there is more connective tissue involvement, Phase I and II should be progressed with more caution to ensure adequate healing. 12/23/2012

40. Progression to the next phase is based on Clinical Criteria and/or Time Frames as appropriate. 12/23/2012

41. Pain Management Adequate pain control after TKA is important in expediting patient progress with mobility and range of motion after surgery. This in turn may result in a shorter hospital stay and improved patient satisfaction. 12/23/2012

42. Pain management following TKA at is multimodal and may include: Pre-operative dose of medications including Acetaminophen and/or Celebrex. Spinal or epidural analgesia Administered as a continuous infusion or as a one-time dose, lasting 6-8 hours. Intrathecal opioids may be added to the anesthetic cocktail. Side effects of epidural injection may include low blood pressure and decreased motor function. If a continuous infusion is used, it is typically stopped at 6 am on post-operative day #1. 12/23/2012

43. Peripheral nerve blocks Femoral and/or sciatic nerve blocks may be administered as a continuous infusion for a period following surgery, or as a one-time dose, lasting 6-8 hours. If a continuous infusion is used, it is typically stopped at 6am on post-operative day #1. Potential side-effects may include nerve damage and a lack of muscle control in the immediate post-operative period. IV or oral analgesics This may include use of an opioid Patient- Controlled Analgesia (PCA). Post-operative pain medications may include opiods (short-acting and continuous-release Oxycodone, Dilaudid, Morphine), centrally-acting 12/23/2012 analgesics(Acetaminophen), anti-inflammatory agents(NSAIDs, COX-2

44. Local analgesics- intra-articular or periarticular injections during TKA surgery may be used for post- operative pain control and to improve range-of-motion (ROM). Intra-articular injections may include a combination of ropivicaine, epinephrine, Ketorlac, and clonididne. Due to the use of epidural anesthesia and/or peripheral nerve blocks, it is important to assess the extent of motor and sensory block the first 48 hours after surgery. Patients must demonstrate adequate quadriceps and lower extremity motor control to participate safely in out-of-bed (OOB) activities. 12/23/2012

45. Phase I Immediate Post Surgical Phase (Day 0-3):The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity and maximize patients mobility with a goal of functional independence.Physical therapy interventions are also directed towards identifying other sensorimotor or systemic conditions that may influence a patients 12/23/2012 rehabilitation potential.

46. Goals: The patient will:1. Perform bed mobility and transfers with the least amount of assistance while maintaining appropriate weight bearing (WB) precautions.2. Ambulate with an assistive device for 25-100 feet and ascend/descend stairs to allow for independence with household activities while maintaining appropriate WB.3. Regain at least 80 degrees of passive and active range of motion in the knee to perform sit to stand transfers with minimal compensatory activity.4. Gain knee extension less than or equal to -10 degrees.5. Independently perform operative extremity Straight Leg Raise (SLR) exercise.6. Verbalize understanding of post-operative activity recommendations/precautions including use of proper positioning of the lower extremity, range of motion and strengthening exercises.7. Patients will also be educated on superficial massage of the 12/23/2012 knee joint to minimize hypersensitivity following surgery.

47. Use of a Continuous Passive Motion(CPM) machine is not part of the standard of care for patients s/p TKR. Use of a CPM may be indicated according to surgeon preference, or in cases where post- operative knee ROM is severely restricted due to revision or reconstructive surgery, severe post- operative pain, limb girth and/or edema, or impaired ability to participate in ROM exercises. 12/23/2012

48. Observation and Assessment: Observe for any signs of deep vein thrombosis (DVT): increased swelling, erthema, calf pain. 12/23/2012

49. If a large amount of drainage is present, or there is blistering or frail skin around the knee joint or the lower extremities, discuss with the nurse and decide if notifying the surgical team is indicated. Assess patients pain using the visual analogue scale. Ensure that patients are premedicated with oral/IV pain medication 30-60 minutes prior to treatment. Cryotherapy is recommended following physical therapy treatment to reduce pain, discomfort and swelling in the knee joint. 12/23/2012

50. Therapeutic exercise and functional mobility: Active/active assisted/passive (A/AA/PROM) exercises (seated and supine). Patella femoral and tibial femoral joint mobilization and soft tissue mobilization as indicated. Soft tissue massage. Isometric quadriceps, hamstring, and gluteal isometric exercises. Straight leg raises (SLR) Lower extremity range of motion (ROM) and strengthening as indicated based on evaluation findings. Closed chain exercises (if patient demonstrates good pain control, muscle strength and balance). Close-chained exercises should be performed with bilateral upper extremity support while maintaining appropriate WB precautions. Gait training on flat surfaces and on stairs. Transfer training. 12/23/2012

51. Modalities: Continuous Cryotherapy for 72 hours after surgery, or at least 5 times/day. Patients are encouraged to use cryotherapy for 20 minutes before and after their independent exercise program. 12/23/2012

52. Precautions: Weight bearing as tolerated (WBAT) with assistive device (unless indicated otherwise by the surgeon) to full weight bearing. Monitor wound healing and consult with referring MD if signs and symptoms of excessive bleeding and poor incision integrity are present. Monitor for signs of DVT, pulmonary embolism (PE), and/or loss of peripheral nerve integrity. In these cases, notify the MD immediately. No exercises with weights or resistance. Avoid torque or twisting forces across the knee joint especially when WB on involved limb. Positioning: A trochanter roll should be used as needed to maintain 12/23/2012 neutral hip rotation and promote knee extension.

53. A towel roll should be placed at the ankle to promote knee extension when patients are supine in bed. Nothing should be placed behind the operative knee, to promote maximal knee extension and prevent knee flexion contracture. 12/23/2012

54. Criteria for progression to the next phase: Ability to demonstrate Quadriceps contraction and/or perform a straight leg raise (SLR) Active knee range of motion (AROM) -10-80 Minimal pain and inflammation Independent transfers and ambulation at least 100 feet with appropriate assistive device. 12/23/2012

55. 12/23/2012

56. 12/23/2012

57. 12/23/2012

58. 12/23/2012

59. 12/23/2012

60. 12/23/2012

61. 12/23/2012

62. 12/23/2012

63. 12/23/2012

64. Thank u 12/23/2012