Total knee replacement
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Transcript of Total knee replacement
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IRENE TOHPRINCIPAL PHYSIOTHERAPIST
PHYSIOTHERAPY DEPARTMENTSINGAPORE GENERAL HOSPTIAL
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Indications Indications
• Severe arthritic changes/deformities– Resulting in severe knee pain despite use of medications and
exercise
– Affecting activities of daily living (eg….)
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COMMON TYPES OF KNEE REPLACEMENT
– Total Knee Replacement / Arthroplasty
– Unicompartmental Knee Arthroplasty
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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%)
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• 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
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POST OPERATIVE DAY 1POD 1
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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.
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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
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Edema control
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CONTINUOUS PASSIVE MOTION (CPM) MACHINE
ASSISTED FLEXION
Ways to improve knee flexion range
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Post operation ExercisesPost operation Exercises
Knee flexion
Static quads Straight leg raise
Inner range quads
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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
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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.
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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
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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
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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.
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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.
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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
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Exercises with free weights
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Exercise with machines
Hip abduction
Leg press
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Hip extension
Balance exercise on foam
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Exercise using therabands
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Steps Concentric and Eccentric Ex
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Outpatient Rehab Program
Exercise prescriptions- Need to consider- Load- Repetitions- Sets
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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
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Knee Assessment
• ROM – flexion and extension
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Knee assessment
• Manual Muscle Testing(on some pts)
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TKR performed in Singapore General Hospital
Year SGH2004 1105
2010 1308
2011 1471
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Outcome measures
Data from 2009-2010
Pre Op 6 mth 2 yearsKnee ROM(deg)
8 - 117 5 – 114 2 – 117
Knee Score(100)
37 83 87
Function Score (100)
51 67 73
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