Total knee replacement
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Transcript of Total knee replacement
IRENE TOHPRINCIPAL PHYSIOTHERAPIST
PHYSIOTHERAPY DEPARTMENTSINGAPORE GENERAL HOSPTIAL
Indications Indications
• Severe arthritic changes/deformities– Resulting in severe knee pain despite use of medications and
exercise
– Affecting activities of daily living (eg….)
COMMON TYPES OF KNEE REPLACEMENT
– Total Knee Replacement / Arthroplasty
– Unicompartmental Knee Arthroplasty
Possible Post Op ComplicationsPossible Post Op Complications
• Deep vein thrombosis (DVT)
• Excessive blood loss
• Knee stiffness
• Flexion contractures
• Peroneal nerve injury
• Periprosthetic fracture (1-5%)
• Instability / dislocation
• Wound / Implant infection (1-2.5%)
• Fear (patient, family, therapist?)
• Lack of education on rehab post operation
• Pain
• Side effects of anaesthesia • Nauesa• Giddiness • Muscle weakness (femoral nerve block)
Factors limiting early ambulationFactors limiting early ambulation
POST OPERATIVE DAY 1POD 1
Physiotherapy Goals
• Optimise respiratory and circulatory functions– Encourage deep breathing exercises to maintain lung
function– Encourage ankle pumps for lower limb circulation. – TEDS stockings
• Begin knee range of motion ex (flexion and extension)– Continuous passive motion machine (CPM) – done for 1
hr each time, up to 2 times a day. – To prevent flexion contractures, position knee in
extension when on bed.
Physiotherapy Goals
• Facilitate recovery of quads strength– Static quads setting (good for knee extension range)– Assisted straight leg raises
• Reduce post op oedema– Ice– TEDs / tubigrip– Early mobilisation and exercise
• Promote early ambulation (Depending on surgeon’s order)– Allowed to weight bear as tolerated unless indicated by
surgeon– Normally start with a walking frame
Edema control
CONTINUOUS PASSIVE MOTION (CPM) MACHINE
ASSISTED FLEXION
Ways to improve knee flexion range
Post operation ExercisesPost operation Exercises
Knee flexion
Static quads Straight leg raise
Inner range quads
POD 2 onwards• Continue with deep breathing exercise as
necessary
• Knee ROM– knee extension 0 degree ** – knee flexion as tolerated
• Continue knee strengthening / quads facilitation– Static quads / Inner range quads– Straight leg raises – Neuromuscular electrical stimulation as
necessary
• Swelling management– Ice (20mins, 3 times a day)– Retrograde massage
POD 2 onwards
• Encourage independent bed mobility
• Ambulate with walking frame / crutches / quadstick as deem safe for patient.
• Commerce stair training if patient is steady on level ground.
Discharge CriteriaDischarge Criteria
• Knee Range of motion = 0° - 90°
• Able to ambulate safely with aids
• Able to climb stairs (depending on home environment)
• Average length of stays = 4-5 Days
Discharge InstructionsDischarge Instructions
• Early rehab is critical for faster recovery and long term results of
surgery
• Resume activities of daily living gradually
• Avoid excessive stairs climbing
• Avoid jumping, kneeling or squatting
• Look out for signs of infections
• Continue with home exercise program and ice therapy daily
• Continue to practice walking with walking aids daily
• Return for outpatient rehab program
Outpatient Rehabilitation Program
Goals• To assist in further pain and swelling
management • To improve knee range to 0-120 deg• To improve knee strength to 5/5 on manual
testing• To progress gait and improve balance• To assist in return to work and function.
Outpatient Rehab
• Return for physio outpatient within 1 week of discharge from hospital.
• Frequency: once every 1-2 weeks.
• Follow up for about 3-4 months / 8-12 sessions.
• Each session duration: 45mins to 1 hr.
Outpatient Rehab Program
• Continue with knee range of motion exercise – Important to achieve 0 degree knee
extension** and 120 degree of knee flexion if possible.
• Progress knee/hip strengthening exercise with free weights / machines
• Balance training
• Gait retraining
Exercises with free weights
Exercise with machines
Hip abduction
Leg press
Hip extension
Balance exercise on foam
Exercise using therabands
Steps Concentric and Eccentric Ex
Outpatient Rehab Program
Exercise prescriptions
- Need to consider- Load
- Repetitions
- Sets
Knee assessments
- Pre op, 6mths, 2yrs (for all pts)- 1mth, 3mths, 5yrs (for some pts)
Questionnaires -• Knee Society Clinical Rating
Scale – Knee score and Function Score
• Oxford Knee Score• SF36
Standing varus and valgus angle
Knee Assessment
• ROM – flexion and extension
Knee assessment
• Manual Muscle Testing
(on some pts)
TKR performed in Singapore General Hospital
Year SGH
2004 1105
2010 1308
2011 1471
Outcome measures
Data from 2009-2010
Pre Op 6 mth 2 years
Knee ROM(deg)
8 - 117 5 – 114 2 – 117
Knee Score(100)
37 83 87
Function Score (100)
51 67 73