Total Knee Arthroplasty and rehab protocol- dnbid

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Total Knee Arthroplasty Protocol: 

Dr. D. N. Bid Sarvajanik College of Physiotherapy, Surat . Total Knee Arthroplasty Protocol 12/23/2012

Introduction: 

Introduction TKA is one of the most successful and commonly performed orthopedic surgery. The best results for TKA at 10 – 15 yrs. compare to or surpass the best result of THA.

Indications for Knee Arthroplasty: 

Indications for Knee Arthroplasty

Indications for TKA: 

Indications for TKA Relieve pain caused by osteoarthritis of the knee (the most common). Deformity in patients with variable levels of pain: Flexion contracture > 20 degrees. Severe varus or valgus laxity.

Osteoarthritis : 

Osteoarthritis American College of Rheumatology classification criteria: Knee pain and radiographic osteophytes and at least 1 of the following 3 items: Age >50 years. Morning stiffness <=30 minutes in duration. Crepitus on motion.

Contraindications for TKA: 

Contraindications for TKA Recent or current knee sepsis. Remote source of ongoing infection. Extensor mechanism discontinuity or severe dysfunction. Painless, well functioning knee arthrodesis. Poor health or systemic diseases (relative contraindications).

Unicondylar Knee Arthroplasty : 

Unicondylar Knee Arthroplasty Indications: Younger patients with unicompartmental disease instead of HTO. Elderly thin patient with unicompartmental disease (shorter rehabilitation, greater ROM) Contraindications: Flexion contracture >= 5 degrees. ROM < 90 degrees. Angular deformity >= 15 degrees. Cartilaginous erosion in the weight-bearing area of the opposite compartment.

Patellar Resurfacing : 

Patellar Resurfacing Indication for leaving the patella unresurfaced: Congruent patellofemoral tracking. Normal anatomical patellar shape. No evidence of crystalline or inflammatory arthropathy. Lighter patient.

Classification: 

Classification

Classification : 

1- Cruciate retaining 2- Cruciate substituting 3- Mobile bearing 4- Unicondylar Classification 1 2 3 4

Degrees of Freedom: 

Degrees of Freedom Constrained Prostheses Non-constrained Prostheses Intermediated Prostheses

Constrained Prostheses: 

Constrained Prostheses Hinged implants. One degree of freedom.

Non-constrained Prostheses: 

Non-constrained Prostheses Ideal implants. 5 degrees of freedom. Intact ligamentous system.

Intermediated Prostheses : 

Intermediated Prostheses Anterior-posterior stability. Two types: FREEMAN (a cylinder in a non conforming trough). INSALL (posterior stabilized knee).

Intermediated Prostheses: 

Intermediated Prostheses Freeman Insall

Longitudinal Alignment Of Knee: 

Longitudinal Alignment Of Knee Tibial components are implanted perpendicular to the mechanical axis. Femoral component is implanted in 5 – 6 degrees of valgus.

Longitudinal Alignment Of Knee: 

Longitudinal Alignment Of Knee Posterior tibial tilt is about 5 – 7 degrees. Usually depend on the articular design. Anatomic tilt 5 degrees

Rotational Alignment Of Knee: 

Rotational Alignment Of Knee Create a rectangular flexion space. External rotation of the femoral component 3 degrees.

Role of PCL – Femoral Roll-Back: 

Role of PCL – Femoral Roll-Back

Role of PCL – Femoral Roll-Back: 

Role of PCL – Femoral Roll-Back

PCL-retention or PCL-substitution ?: 

PCL-retention or PCL-substitution ? PCL retaining prostheses: Better ROM (roll-back, flat tibial surface). More symmetrical gait (stair climbing). Less femoral bone resection is required. PCL needs to be accuracy balanced. PCL substituting prostheses: Easier surgical exposure. See-saw effect prevention. Lower tibial polyethylene contact stress Posterior tibial component displacement. Patella clunk syndrome.

PCL-retention or PCL-substitution ?: 

PCL-retention or PCL-substitution ?

PCL-retention or PCL-substitution ?: 

PCL-retention or PCL-substitution ?

Patellofemoral Joint: 

Patellofemoral Joint Limb with larger Q angle has a greater tendency for lateral subluxation. Preventing subluxation: Prosthetic component. Vastus medialis (in early flexion).

Surgical Technique for Primary TKA: 

Surgical Technique for Primary TKA

Preoperative Evaluation: 

Preoperative Evaluation Soft tissue defects around the knee. Vascular status to the limb. Extensor mechanism. Preoperative range of motion. Standing (AP) view, a lateral view of the knee, and a skyline view of the patella.

Surgical Preparation: 

Surgical Preparation Administer a dose of a 1 st generation cephalosporin (or vancomycin, clindamycin) Avoid pressure on peripheral nerves.

Surgical Approaches : 

Surgical Approaches Medial parapatellar retinacular approach. Subvastus approach. Midvastus approach.

Varus Deformity: 

Varus Deformity 1 st Osteophytes must be removed. 2 nd Release the deep MCL. 3 rd Release semimembranosus and pes anserinus insertion. 4 th release posterior capsule and PCL.

Varus Deformity: 

Varus Deformity

Valgus Deformity: 

Valgus Deformity 1 st Remove all osteophytes. 2 nd release lateral capsule. 3 rd Lesser deformity: release Iliotibial band. Greater deformity: release LCL +/- PCL. Valgus deformity + flexion contracture >> release posterior capsule.

Valgus Deformity: 

Valgus Deformity

Flexion Contracture: 

Flexion Contracture Extension gap < Flexion gap >> more distal femoral bone cut, posterior capsule release. Flexion gap < Extension gap >> larger tibial insert.

Postoperative Management : 

Postoperative Management

Total knee replacement exercise protocol Outline: 

Total knee replacement exercise protocol Outline Postoperative day 1 Bedside exercises (e.g. ankle pumps, quadriceps exercises…) Postoperative day 2 Exercises for active ROM and terminal knee extension Gait training with assistive device Postoperative day 3-5 Progression of ambulation on level surfaces and stairs (if applicable) Postoperative day 5 to 4 weeks Stretching of quadriceps and hamstring muscles Progression of ambulation distance

Complications of Total Knee Arthroplasty: 

Complications of Total Knee Arthroplasty Thromboembolism. Infection. Neurovascular complications. Patellofemoral complications. Periprosthetic fractures.

Brigham and Women’s Hospital Protocol: 

Brigham and Women’s Hospital Protocol 12/23/2012

Brigham and Women’s Hospital Protocol: 

Brigham and Women’s Hospital Protocol The intent of this physical therapy protocol is to provide the clinician with a guideline of the post-operative rehabilitation course of a patient who has undergone a total knee arthroplasty (TKA). It is by no means intended to be a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course based on their physical exam/findings, individual progress, and/or the presence of post-operative complications. 12/23/2012

PowerPoint Presentation: 

This physical therapy protocol applies to primary total knee arthroplasty. In a revision total knee arthroplasty, or in cases where there is more connective tissue involvement, Phase I and II should be progressed with more caution to ensure adequate healing. 12/23/2012

PowerPoint Presentation: 

Progression to the next phase is based on Clinical Criteria and/or Time Frames as appropriate. 12/23/2012

PowerPoint Presentation: 

Pain Management Adequate pain control after TKA is important in expediting patient progress with mobility and range of motion after surgery. This in turn may result in a shorter hospital stay and improved patient satisfaction. 12/23/2012

PowerPoint Presentation: 

Pain management following TKA at is multimodal and may include: • Pre-operative dose of medications including Acetaminophen and/or Celebrex. • Spinal or epidural analgesia– Administered as a continuous infusion or as a one-time dose, lasting 6-8 hours. Intrathecal opioids may be added to the anesthetic cocktail. Side effects of epidural injection may include low blood pressure and decreased motor function. If a continuous infusion is used, it is typically stopped at 6 am on post-operative day #1. 12/23/2012

PowerPoint Presentation: 

Peripheral nerve blocks – Femoral and/or sciatic nerve blocks may be administered as a continuous infusion for a period following surgery, or as a one-time dose, lasting 6-8 hours. If a continuous infusion is used, it is typically stopped at 6am on post-operative day #1. Potential side-effects may include nerve damage and a lack of muscle control in the immediate post-operative period. • IV or oral analgesics – This may include use of an opioid Patient-Controlled Analgesia (PCA). Post-operative pain medications may include opiods (short-acting and continuous-release Oxycodone , Dilaudid , Morphine), centrally-acting analgesics(Acetaminophen), anti-inflammatory agents(NSAIDs, COX-2 inhibitors, Ketorolac ), α-agonists( Gabapentin , Tramadol ), and/or transdermal patches (typically an opioid such as Fentanyl , used in conjunction with oral pain regiment). 12/23/2012

PowerPoint Presentation: 

• Local analgesics- intra- articular or periarticular injections during TKA surgery may be used for post-operative pain control and to improve range-of-motion (ROM). Intra- articular injections may include a combination of ropivicaine , epinephrine, Ketorlac , and clonididne . Due to the use of epidural anesthesia and/or peripheral nerve blocks, it is important to assess the extent of motor and sensory block the first 48 hours after surgery. Patients’ must demonstrate adequate quadriceps and lower extremity motor control to participate safely in out-of-bed (OOB) activities. 12/23/2012

PowerPoint Presentation: 

Phase I – Immediate Post Surgical Phase (Day 0-3): The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity and maximize patients’ mobility with a goal of functional independence. Physical therapy interventions are also directed towards identifying other sensorimotor or systemic conditions that may influence a patients’ rehabilitation potential. 12/23/2012

PowerPoint Presentation: 

Goals: The patient will: 1. Perform bed mobility and transfers with the least amount of assistance while maintaining appropriate weight bearing (WB) precautions. 2. Ambulate with an assistive device for 25-100 feet and ascend/descend stairs to allow for independence with household activities while maintaining appropriate WB. 3. Regain at least 80 degrees of passive and active range of motion in the knee to perform sit to stand transfers with minimal compensatory activity. 4. Gain knee extension less than or equal to -10 degrees. 5. Independently perform operative extremity Straight Leg Raise (SLR) exercise. 6. Verbalize understanding of post-operative activity recommendations/precautions including use of proper positioning of the lower extremity, range of motion and strengthening exercises. 7. Patients will also be educated on superficial massage of the knee joint to minimize hypersensitivity following surgery. 12/23/2012

PowerPoint Presentation: 

Use of a Continuous Passive Motion(CPM) machine is not part of the standard of care for patient’s s/p TKR. Use of a CPM may be indicated according to surgeon preference, or in cases where post-operative knee ROM is severely restricted due to revision or reconstructive surgery, severe post-operative pain, limb girth and/or edema, or impaired ability to participate in ROM exercises. 12/23/2012

PowerPoint Presentation: 

Observation and Assessment: • Observe for any signs of deep vein thrombosis (DVT): increased swelling, erthema , calf pain. 12/23/2012

PowerPoint Presentation: 

• If a large amount of drainage is present, or there is blistering or frail skin around the knee joint or the lower extremities, discuss with the nurse and decide if notifying the surgical team is indicated. • Assess patients’ pain using the visual analogue scale. Ensure that patients are premedicated with oral/IV pain medication 30-60 minutes prior to treatment. Cryotherapy is recommended following physical therapy treatment to reduce pain, discomfort and swelling in the knee joint. 12/23/2012

PowerPoint Presentation: 

Therapeutic exercise and functional mobility: • Active/active assisted/passive (A/AA/PROM) exercises (seated and supine). • Patella femoral and tibial femoral joint mobilization and soft tissue mobilization as indicated. • Soft tissue massage. • Isometric quadriceps, hamstring, and gluteal isometric exercises. • Straight leg raises (SLR) • Lower extremity range of motion (ROM) and strengthening as indicated based on evaluation findings. • Closed chain exercises (if patient demonstrates good pain control, muscle strength and balance). Close-chained exercises should be performed with bilateral upper extremity support while maintaining appropriate WB precautions. • Gait training on flat surfaces and on stairs. • Transfer training. 12/23/2012

PowerPoint Presentation: 

Modalities: • Continuous Cryotherapy for 72 hours after surgery, or at least 5 times/day. • Patients are encouraged to use cryotherapy for 20 minutes before and after their independent exercise program. 12/23/2012

PowerPoint Presentation: 

Precautions: • Weight bearing as tolerated (WBAT) with assistive device (unless indicated otherwise by the surgeon) to full weight bearing. • Monitor wound healing and consult with referring MD if signs and symptoms of excessive bleeding and poor incision integrity are present. • Monitor for signs of DVT, pulmonary embolism (PE), and/or loss of peripheral nerve integrity. In these cases, notify the MD immediately. • No exercises with weights or resistance. • Avoid torque or twisting forces across the knee joint especially when WB on involved limb. Positioning: • A trochanter roll should be used as needed to maintain neutral hip rotation and promote knee extension. 12/23/2012

PowerPoint Presentation: 

• A towel roll should be placed at the ankle to promote knee extension when patients are supine in bed. • Nothing should be placed behind the operative knee, to promote maximal knee extension and prevent knee flexion contracture. 12/23/2012

PowerPoint Presentation: 

Criteria for progression to the next phase: • Ability to demonstrate Quadriceps contraction and/or perform a straight leg raise (SLR) • Active knee range of motion (AROM) -10°-80° • Minimal pain and inflammation • Independent transfers and ambulation at least 100 feet with appropriate assistive device. 12/23/2012

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Thank u…………: 

Thank u………… 12/23/2012