Podcast
Questions and Answers
What is the recommended weight-bearing status immediately post-operation for patients with cemented total knee replacements?
What is the recommended weight-bearing status immediately post-operation for patients with cemented total knee replacements?
How long should patients avoid twisting and turning after a knee replacement operation?
How long should patients avoid twisting and turning after a knee replacement operation?
At what point should patients with cemented total knee replacements begin ambulation with a cane?
At what point should patients with cemented total knee replacements begin ambulation with a cane?
What is the expected range of motion for patients on cemented total knee replacements within 3-4 weeks?
What is the expected range of motion for patients on cemented total knee replacements within 3-4 weeks?
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Which of the following exercises should be initiated immediately post-operation?
Which of the following exercises should be initiated immediately post-operation?
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What percentage of body weight can patients with cemented-less total knee replacements expect to bear by week 10?
What percentage of body weight can patients with cemented-less total knee replacements expect to bear by week 10?
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If a patient has a slightly swollen and painful knee three days post-operation after exercising, what might be a likely concern?
If a patient has a slightly swollen and painful knee three days post-operation after exercising, what might be a likely concern?
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What general functionality can be expected from the best knee replacements compared to total hip replacements?
What general functionality can be expected from the best knee replacements compared to total hip replacements?
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Which type of knee arthroplasty involves replacing both the medial and lateral compartments of the knee?
Which type of knee arthroplasty involves replacing both the medial and lateral compartments of the knee?
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What is the main goal of knee arthroplasty?
What is the main goal of knee arthroplasty?
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Which of the following is NOT a contraindication for knee arthroplasty?
Which of the following is NOT a contraindication for knee arthroplasty?
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What is the recommended exercise on the first postoperative day?
What is the recommended exercise on the first postoperative day?
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What type of fixation is characterized as not using cement?
What type of fixation is characterized as not using cement?
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What should be assessed during the preoperative rehabilitation visit?
What should be assessed during the preoperative rehabilitation visit?
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In which type of knee arthroplasty is the patellofemoral articulation resurfaced?
In which type of knee arthroplasty is the patellofemoral articulation resurfaced?
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Which exercise helps minimize deep vein thrombosis (DVT) on the first postoperative day?
Which exercise helps minimize deep vein thrombosis (DVT) on the first postoperative day?
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What is one reason for performing quadriceps sets 10 times hourly throughout the day?
What is one reason for performing quadriceps sets 10 times hourly throughout the day?
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What should be done once the pressure bandage and splint are removed after 4 days?
What should be done once the pressure bandage and splint are removed after 4 days?
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What is the recommended daily increase for knee flexion after surgery?
What is the recommended daily increase for knee flexion after surgery?
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When is unsupported weight bearing typically started in a patient using a CPM machine?
When is unsupported weight bearing typically started in a patient using a CPM machine?
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What is a disadvantage of using a CPM machine in the early stage of recovery?
What is a disadvantage of using a CPM machine in the early stage of recovery?
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By the 7th postoperative day, what range of active knee flexion should a patient normally achieve?
By the 7th postoperative day, what range of active knee flexion should a patient normally achieve?
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In which scenario is CPM not recommended?
In which scenario is CPM not recommended?
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How often should active assisted knee flexion be performed after the splint is removed?
How often should active assisted knee flexion be performed after the splint is removed?
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What can be done to address extensor lag in patients using CPM?
What can be done to address extensor lag in patients using CPM?
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What is a recommended method to stretch the posterior aspect of a prosthetic knee?
What is a recommended method to stretch the posterior aspect of a prosthetic knee?
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How long are crutches or a walker recommended for patients with a cemented prosthesis?
How long are crutches or a walker recommended for patients with a cemented prosthesis?
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What should a patient avoid doing while walking after knee surgery?
What should a patient avoid doing while walking after knee surgery?
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What is the main concern with proprioception loss after a knee replacement?
What is the main concern with proprioception loss after a knee replacement?
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What activity is advised during the initial phase of stair climbing rehabilitation?
What activity is advised during the initial phase of stair climbing rehabilitation?
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What is a recommended functional rehabilitation exercise starting from week 3?
What is a recommended functional rehabilitation exercise starting from week 3?
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What is one way to help patients with a quadriceps lag while on CPM?
What is one way to help patients with a quadriceps lag while on CPM?
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Study Notes
Knee Arthroplasty Rehabilitation
- Knee arthroplasty is a surgical procedure to construct a new, artificial, painless, movable, and stable knee joint.
- Indications for surgery include severe painful joints, with or without deformity.
- Secondary causes of needing knee arthroplasty include rheumatoid arthritis, osteoarthritis, and traumatic arthritis.
- Contraindications to surgery include bone infection, severe osteoporosis, recent joint sepsis, and malignant tumors.
Knee Arthroplasty Classifications
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Classifications based on the portion of the knee replaced:
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Uni-compartmental: Replacing opposing articular surfaces of the femur and tibia, either medial or lateral compartment; often has poor results.
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Bi-compartmental: Replacing the opposing articular surfaces of the femur and tibia, including both medial and lateral compartments.
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Tri-compartmental: Similar to bi-compartmental, but also resurfacing the patellofemoral articulation.
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Classifications based on mechanical constraint:
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Un-constrained
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Semi-constrained
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Fully constrained
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Classifications based on the type of fixation:
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Cemented
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Cementless
Preoperative Rehabilitation
- A preoperative visit records baseline information, including pain, swelling, functional abilities, range of motion (ROM), and muscle strength.
- Patients practice exercises, like isometric quadriceps, that will be used post-surgery.
- Training on walking aids like walkers or crutches is crucial.
- If a continuous passive motion (CPM) machine is available, patients should try it before surgery.
Early Postoperative Stage (Day One)
- Deep breathing and coughing are crucial to avoid pressure sores.
- Ankle pumps should be performed 10 times every 2 hours to improve circulation and reduce the risk of deep vein thrombosis (DVT).
- Gluteal sets, upper extremity exercises, patella movement are a part of the daily routine.
- Quadriceps sets are repeated hourly throughout the day; this helps reduce joint effusion, pain-induced muscle inhibition, and improve inner range strength.
- Patients should prepare themselves for the sliding leg raising (SLR) exercises.
Two Main Forms of Management (No CPM)
- The knee is maintained in an extended position for 4 days using a pressure bandage and splint.
- A large compression bandage is applied.
- A back splint keeps the leg straight to prevent movement and reduce pain.
- Active exercises are not allowed until the splint is removed.
- Assisted weight bearing is possible from day two.
Postoperative Mobilization (After the splint removal)
- Patients will do passive mobilization of the patella and the scar. This helps relieve knee pain and increases flexion.
- Start active assisted knee flexion exercises at least twice a day for 20 minutes.
- Patients usually go home 5-6 days post-operation (without complications).
- Goal by postoperative day 7 is for 50-70 degrees of active knee flexion.
Return of Knee Flexion, 50-70 Degrees
- Continue the process of increasing knee flexion by at least 10 degrees every day at home.
- If 50-70 degrees of flexion isn't met on day 7, start continuous passive motion (CPM) machine for at least 6 hours per day to maximize knee flexion.
- The knee should reach 80-90 degrees of flexion by day 14.
- If a CPM machine is unavailable, manipulation under anesthesia could be considered.
- Water therapy is helpful if available.
Continuous Passive Motion (CPM) Machine
- CPM is used immediately post-operatively (up to 4 days).
- CPM is applied to control knee flexion to 40 degrees in the first 24 hours and gradually increase up to 80-90 degrees until day 7.
Disadvantages of CPM
- Increased time in bed
- Loss of independence due to extended use of CPM
- Discomfort related to CPM use
- Incidence of common peroneal nerve palsy
- Patients using CPM often develop quadriceps lag, so a splint may be needed at night to prevent knee flexion.
Extensor Lag or Fixed Flexion Deformity
- This is common amongst patients on CPM due to an imbalance between gain in flexion and extension.
- Several exercises are done to overcome this issue like:
- Progressing passive knee flexion until the extensor lag is reduced.
- Utilizing gentle manual mobilization techniques.
- Performing inner range quadriceps strengthening and hamstring/posterior knee stretching.
Functional Rehabilitation
- Begins in week 3.
- Includes closed-chain exercises (sitting to standing from varying heights, step-ups, and stationary cycling).
Proprioception Training
- Loss of proprioception is common post-replacement, exacerbated by ACL and joint capsule removal.
Walking
- Patients should use crutches or a walker for 6 weeks (cemented prostheses) or 12 weeks (cementless prostheses), and then a cane for 4-6 months.
- Walk rhythmically and smoothly, without hurrying.
- Adjust step length and speed, gradually increasing weight bearing on the affected leg.
- Use a crutch or cane on the unaffected side.
- Avoid limping or leaning away from the operated knee.
Stairs
- Initially, use handrails and ascend/descend stairs one step at a time ("up with the good, down with the bad").
- As strength improves, ascend/descend stairs foot over foot.
Driving, Jumping, and Running
- Knee joint proprioception and inner range quadriceps strength/ROM are required for driving.
- Avoid twisting, turning, jumping and running for at least 3 months (some surgeons recommend 6 months).
- Best knee implants offer near 80-85% of normal function.
- Total knee replacement is mechanically simpler than total hip replacement, likely leading to 90-95% of normal function.
Activity Guidelines (Cemented vs. Cementless)
- Cemented and cementless prostheses have slightly varying guidelines for range of motion, isometric exercises, active exercises, and resisted exercises. Specific timing for each is described in the table.
- Postoperative ambulation guidance (partial vs. full weight bearing) differs based on cemented or cementless prosthesis.
Problem Solving Exercises (Example)
- A patient with a 3-day-old knee implant showing increased swelling and warmth after exercise could indicate infection or DVT.
- Addressing these conditions involves body temperature checks, swelling checks, pain evaluation for DVT assessment, and applying ice.
Important Notes
- This information is for educational purposes only. Consult with a medical professional for specific instructions regarding your condition.
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Description
This quiz covers important aspects of knee arthroplasty rehabilitation, including indications, contraindications, and surgical classifications. Learn about the different types of knee replacements, such as uni-compartmental, bi-compartmental, and tri-compartmental. Test your knowledge on both the surgical procedures and postoperative care involved in knee arthroplasty.
