21 Knee Arthroplasty Rehabilitation PDF

Rehabilitation After Knee Arthroplasty Mona Selim  Classifications Knee Arthroplasty is : Surgical construction of newly artificial, painless, movable and stable knee joint According to the replaced portion of the knee: Uni-compartmental Bi-compartmental Tr...

Rehabilitation After Knee Arthroplasty Mona Selim  Classifications Knee Arthroplasty is : Surgical construction of newly artificial, painless, movable and stable knee joint According to the replaced portion of the knee: Uni-compartmental Bi-compartmental Tri-compartmental According to mechanical constrain: Un-constraint Semi-constraint Fully -constraint According to type of fixation: Mona Selim Cemented Cemented-less Indications Knee arthroplasty was designed to relieve pain, provide motion, stability and correct deformity. So the indications are sever painful joint with or without deformity SECONDARY TO 1. Rheumatoid arthritis 2. Osteoarthritis 3. Traumatic arthritis Contraindications 1. Bone infection 2. Severe osteoporosis 3. Recent joint sepsis 4. Malignant tumours. Mona Selim  Mona Selim Classification According to the replaced portion of the knee: 1. Uni-compartmental: Replace opposing articular surfaces of femur and tibia of either medial or lateral compartment of knee, has Poor results 2-Bi-compartmental: provides for the replacement of the opposing articular surfaces of the femur and tibia of both medial and lateral compartments of knee 3.Tri-compartmental: Same as Bi-compartmental + resurfacing the patellofemoral articulation  Preoperative rehabilitation One purpose of the preoperative visit is to record a baseline of information. This includes measurements of : 1. Pain & Swelling 2. Functional abilities & ROM 3. Muscle strength A second purpose to prepare patient for postoperative program: 1. You will practice some of the exercises used just after surgery, e.g. isometric quadriceps. 2. Walking aids should be trained either the use of a walker or crutches. 3. If a CPM machine is to be used the patient should try this before surgery for easy post-surgery Mona Selim  Early postoperative stage Day one post operation. 1. Deep breathing exercises and coughing several times per hour 2. Minimize the chance of pressure sores. 3. ankle pumps 10 times every 2 hours to encourage circulation and minimize DVT 4. gluteal sets 5. upper extremity exercises. 6. Move patella up and down. gluteal sets 7. Quadriceps sets: 10 times repeated hourly throughout the day (why?) To reduce joint effusion To overcome muscle inhibition produced by pain Help to achieve the inner range strength Prepare to do the SLR exercises. (SLR should be attempted after the first two days ) Mona Selim  Two main forms of management 1-No CPM - Knee will be maintained in extended position for 4 days by - pressure bandage & splint. A large compression bandage is applied. A back splint holds the leg in the straightened position to prevent movement and reduce pain. No active exercise to the knee can begin until this is removed. SLR will not be possible at this early stage Assisted weight bearing begins from Day 2. Mona Selim  As soon as this is removed (after 4 days) Passive mobilization of the patella and the scar.(reduce pain and increase flexion) Active assisted knee flexion should begin twice per day for at least 20 minutes Patients discharged home at 5 -6 days (no complications) By the 7th postoperative day the patient must normally have 50-70o of active knee flexion Mona Selim Return of knee flexion should be undertaken at home. Flexion range should be increased by at least 10 degrees per day. If has not reached 50-70 degrees knee flexion by day 7; start CPM taking knee flexion up to its maximum and keeping 6 hours a day. The knee should reach 80 -90 degrees by day 14 If a CPM machine is not available the manipulation under anaesthesia may be indicated Water therapy, if available can be valuable. Mona Selim  2- CPM Use of CPM machine: - Immediately post-operative (in the surgical recovery room)up to 4 days, 6 hours per day - Range of flexion is controlled to 40 over the first 24 hours and increased by 10 per day until 80-90 flexion By day 7. -Active knee flexion will always return much more quickly than with the non- CPM group -Weight bearing with splint can start on postoperative day 2 and without the splint only after quadriceps control. Mona Selim -Unsupported weight bearing is often a day or two later in the CPM group due to greater quadriceps lag. Don’t use CPM for postoperative management of patients following uncomplicated total knee replacement (White n,etal.2015) Mona Selim  Disadvantages of CPM in the early stage: 1. Increased time in bed 2. Loss of independence if on CPM for long periods 3. Discomfort 4. Incidence of common peroneal nerve palsy 5. Patients on CPM have a greater quadriceps lag (what?) and should wear a splint at night or when off the CPM to reduce the possibility of holding the knee in flexion. Mona Selim  Extensor lag or fixed flexion deformity This can be a particular problem for the CPM group and occurs if there is an imbalance between the gain of flexion and of extension. How to solve this problem Mona Selim 1. Progression of passive flexion should be stopped until there is reduction of the extensor lag. 2. Gentle manual mobilization techniques Gd I or II Maitland mobilization can be used to help increase extension (avoid forceful mobilization or PROM>90◦ 3. Inner range quadriceps strengthening exercise 4. Hamstring and posterior knee stretching Mona Selim Mona Selim How to stretch the posterior aspect of a prosthetic knee replacement ? 1. POP, knee extension splint 2. passive knee extension stretch 3. isometric exercises and inner range quadriceps exercise 4. SLR Mona Selim  Functional rehabilitation Starts on week 3 Closed chain exercises e.g. 1. sitting to standing from various heights 2. step ups 3. small arch cycling. Mona Selim Mona Selim Mona Selim Proprioception training Loss of proprioception is normal with any joint replacement but removal of the ACL and joint capsule, exaggerates this loss following a knee replacement. Mona Selim  Walking For cemented prosthesis we recommend that crutches or a walker be used for 6 weeks and then a cane for 4 -6 months For cement-less prosthesis we keep crutches or a walker for 12 weeks. Walking instructions 1. Walk as rhythmically and smooth as you can. 2. Don't hurry. 3. Adjust the length of your step and speed. 4. gradually put more weight on your leg. 5. Use a single crutch or cane in the contralateral hand 6. You should not limp or lean away from your operated knee. Mona Selim  Stairs At first, you will need a handrail for support and will be able to go only one step at a time. Remember, "up with the good" and "down with the bad.". Stair climbing is an excellent strengthening and endurance activity. As you become stronger and more mobile, you can begin to climb stairs foot over foot. Mona Selim  Driving: Knee joint proprioception is definitely needed for driving, along with inner range quadriceps strength and ROM. Not before 6 weeks Avoidance of twisting and turning, jumping and running is essential for at least 3 months post operation some surgeons extend this to 6 months. The best knee replacements are offering about 80-85% of normal function, this is to be contrasted the total hip replacement, which being a simple universal ball and socket joint is much simpler mechanically and probably gives 90- 95% of normal function Mona Selim Total knee replacement Guidelines and Precautions Mona Selim Activity Cemented Cemented-less Range of motion 0-90◦ within 2 weeks 0-90◦ within 2 weeks 0-120◦ within 3-4 weeks 0-120◦ within 3-4 weeks Isometric exercise & Immediately postop. Immediately postop. active exercises Resisted exercises Begin at week 2-3 Begin at week 2-3 Mona Selim Ambulation Cemented Cemented-less Partial weight bearing as tolerated Varies from weight bearing as with walker immediately postop. tolerated (WBAT) to touch- down weight bearing (TDWB) Begin ambulation with cane at based on the surgeon’s week 3 postoperative. philosophy and the surgical approach. Begin transition to full weight bearing at week 4. Mona Selim  Cemented-less Ambulation TDWB: WBAT: Touch down weight bearing with walker weight bearing as tolerated with walker immediately immediately postop. postop. Weight bearing as tolerated with walker at week 6. Begin ambulation with cane at week 5-6. Ambulate with cane at week 8-10. Begin translation to full weight bearing at week 6. Begin transition to full weight bearing at week 10-12. *25% of body weight at 1-7 weeks. 50% by week 8. 75% by week 10. 100% without assistive device by week 12. Mona Selim Mona Selim  Problem-solving exercises A patient with a 3 day old new knee joint is complaining of a hot painful knee joint following exercise. On inspection the knee is slightly more swollen than prior to treatment. Why do you think this has occurred and what would you do about it? Mona Selim  Answer Possible causes are 1. Infection, (patient’s body temperature need to be checked) 2. DVT, (check to see if there are any signs of DVT in the calf e.g. swelling, pain and discomfort) 3. Too much exercise too soon (if flexion is pushed too much in the non-CPM group because they are not moving into flexion as regularly as the CPM group). Ice may be applied to the knee if sensation is intact and the leg elevated to help reduce the signs Mona Selim  Thank you Mona Selim