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