2/16/2019 TOTAL KNEE

REPLACEMENT

MONIKA SHARMA
MPT 1ST YEAR
 ACKNOWLEDGEMENT

The success and final outcome of this assignment required a lot of guidance and
assistancmy assignment work. Whatever I have done is only due to such assistance and
guidance and I would not forget to thank them.
I respect and thank Dr Saru Bansal and Dr Kritika Vats for giving me opportunity to do
the assignment work in given topic and providing me all support and guidance which made
me complete the assignment on time. I am extremely grateful to them for providing such a
nice support and guidance though they had busy schedule managing the college affairs.
I would like to extend our sincere regards to all the non teaching staff of department of
physiotherapy for their timely support.

Monika Sharma
 TABLE OF CONTENT

Total knee replacement

Types of knee replacement

Indications and Contraindications of Total knee replacement (TKR)

Examination

TKR Rehabilitation (Pre and post operative physiotherapy)

Risks and Complications

References
 TOTAL KNEE REPLACEMENT

A total knee replacement is a surgical procedure whereby the diseased knee joint is
replaced with artificial material. The knee is a hinge joint that provides motion at the point
where the thigh meets the lower leg.The femur abuts the large bone of the lower leg (tibia)
at the knee joint. During TKR the end of the femur bone is removed and replaced with a
metal shell. The end of the tibia is also removed and replaced with a channeled plastic piece
with a metal stem. Depending on the condition of the kneecap portion of the knee joint, a
plastic button may also added under the knee cap surface.The artificial components of a
total knee replacement are referred to as PROSTHESIS.
The posterior cruciate ligament is a tissue that normally stablilizes each side of the knee
joint so that lower leg cannot slide backward in relation to thigh bone.In TKR this
ligament is either retained ,sacrificed or substituted by a polyethelene post.
 CLINICALLY RELEVANT ANATOMY

The Knee is a modified hinge joint, allowing motion through flexion and extension, but
also a slight amount of internal and external rotation. There are three bones that form the
knee joint: the upper part of the Tibia , the lower part of the Femur and the Patella. The
bones are covered with a thin layer of cartilage, which ensures that friction is limited. On
both the lateral and medial sides of the knee, there is a meniscus, which adheres the tibia to
the femur, but is also a shock absorber. The three bones are kept together by the ligaments
and are surrounded by a capsule.
 TYPES OF KNEE REPLACEMENT

Knee replacement procedure can be divided in to several categories based on component

design , surgical approach and types of fixation.

1.NUMBER OF COMPARTMENTS REPLACED

*UNICOMPARTMENTAL -only medial or lateral joint surfaces replaced.
* BICOMPARTMENTAL-entire femoral and tibial surfaces replaced.Most TKR
procedures involve a two component,semiconstrained prosthetic system to replace the
proximal tibia and distal femur. These systems typically composed of a modular or non
modular femoral component with a metal articulating surface and a single all polyethelene
or metal backed modular or non modular tibial component with a polyethelene articulating
surface.
* TRICOMPARTMENTAL-In this the femoral, tibial and patellar surfaces are replaced.

2.IMPLANT DESIGN
*DEGREE OF CONSTRAINT
-Unconstrained- no inherent stability in the implant design,used primarily with
unicompartmental arthroplasty.
-Semiconstrained-provides some degree of stability with little compromise of
mobility; most common designs used for total knee arthroplasty.
-Fully constrained-significant congruency of components ;most inherent stability
but considerable limitation of motion.
*fixed bearing or mobile bearing design
*cruciate retaining or cruciate substituting.

3.IMPLANT FIXATION
*CEMENTED-In this the implants are held in place using acrylic cement.A long term
complication associated with early designs of cemented prosthesis was biomechanical
loosening, primarily of ther tibialcomponent at the bone cement interface.
 *UNCEMENTED- One of the main indications for using a cementless TKA is good bone
quality with high metabolic activity, in order to promote biological fixation. Indeed, a
younger age (under 65 years old) and an adequate bone stock are the most typical
indications.

*HYBRID
It combines the cemented fixation of the tibial component and the cementless fixation of the
femoral component.

INDICATIONS AND CONTRAINDICATIONS

INDICATIONS
*severe osteoarthritis
* Older patients with more sedentary life style
*younger patients who have limited function because of systemic arthritis with multiple
joint involvement
*Rheumatoid arthritis
* Osteonecrosis with subchondral collapse of a femoral condyle
*gross instability or limitation of motion
*failure of non operative method or previous surgical procedure.

CONTRAINDICATIONS
ABSOLUTE
*Recent or current joint infection ± unless carrying out an infected revision.
*Sepsis or systemic infection
*Neuropathic arthropathy
*Painful solid knee fusion
RELATIVE CONTRAINDICATIONS

*Severe osteoporosis
* Debilitated poor health
* Non functioning extensor mechanism
*Painless, well functioning arthrodesis
*Significant peripheral vascular disease
*Skin conditions such as PSORIASIS within the operated field
*Recurrent urinary tract infection

EXAMINATION

PRE-OPERATIVE TESTS
First the examiner should ask the patient about the history of complaints and also about
expectations from surgery. The examiner should then perform a full objective examination.
After this different tests could be carried out to determine whether the patient needs total
knee arthroplasty:
*Active ROM
*Passive ROM
*Muscle power
*Functional tasks
 T.K.R REHABILITATION
Pre-operative physiotherapy
GOALS
*Mentally prepare for surgery
*Reduce pain and imflammation
*Normalizing movement patterns prior to surgery
*Improving muscular control of the injured joint
The pre-op knee replacement exercise program starts with some simple range of motion
exercises and progresses through specific strengthening exercises to help prepare your
muscles and knee for the joint replacement surgery.
1.QUADRICEPS STRENGHENING
Restoring normal strength to your quadriceps muscles on the top of your thigh is
important to regain normal function after your total knee surgery. Preparing your quads
for surgery can help you get back to normal strength quickly after your procedure.

2.HEEL SLIDES
Performing heel slides is a great way to help you improve your knee flexion ROM when
preparing for knee replacement surgery. The exercise is simple to do, and it can help your
knee bend and straighten better. To perform the heel slide exercise, lie on your back with
your leg out in front of you. Slowly bend your knee and slide your heel up towards your
buttocks. Bend your knee as far as possible and hold it in the fully bent position for a few
seconds.
3.PRONE HANG EXCERCISE
When prepping for knee replacement surgery, the prone hang exercise is a simple thing to
do to increase knee extension ROM. To do the exercise, simply lie face down on a bed with
your leg hanging over the edge. Your thigh should be supported, but everything from your
kneecap down should be hanging over the edge of the bed.
In the prone hang position, you should feel a slight stretch in the back of your knee or calf.
Remain in the face-down position for 30 to 60 seconds, and then relax the stretch by
bending your knee.

4.STRAIGHT LEG RAISES

Straight leg raises are a great way to strengthen the muscles around your hips and knees in
preparation for your knee replacement surgery. The exercises allow you to contract and
work your leg and thigh muscles while placing minimal stress on your knee joint.
You can perform straight leg raises on your back, your side or on your stomach to work
your hip and thigh muscles in various directions. Perform 10 to 15 reps of straight leg

raises.

5.HAMSTRINGS STRENTHENING
Sit in a chair and bend your knee against the resistance of the band. When your knee is
fully bent, hold the position for a few seconds. You should feel your hamstring behind your
thigh contract. Slowly return to the starting position, and repeat the exercise for 10 to 15

repetitions.

POST-OPERATIVE PHYSIOTHERAPY

EARLY POST OPERATIVE PERIOD

(0 TO 2 WEEKS)
Goals-*control post operative swelling
*minimize pain
* ROM 0 to 90 degrees
*3/5 muscle strength
*ambulate with assistive device
*PAIN CONTROL
After your surgery, you will be given pain medication. Good pain control allows you to
move and become more active.
You will be asked to describe your level of pain on a scale of 0-10. Zero represents no pain
and 10 represents the worst possible pain.
» 1 to 3 = mild pain
» 4 to 6 = moderate pain
» 7 to 10 = severe pain

Prevent vascular and pulmunory complications:

1.Ankle pumping exercises with the leg elevated immediately after surgery to prevent a
DVT .
2.Deep breathing exercises.

Prevent reflex inhibition or loss of strength of knee and hip musculature

1.Muscle strengthening exercises of the quadriceps ,hamstrings
2.Assisted progression to active SLR in supine and prone positions the first day or two
after surgery, postponing SLRs in side – lying positions for 2 weeks after cemented TKA
and for 4-6 weeks after cementless/hybrid replacement to avoid varus or valgus stresses to
the operated knee.
3.Active assisted ROM progressing to assisted ROM of the knee while seated and standing
for gravity -resisted knee extension and flexion,respectively.
4.As weight bearing on the operated lower extremity permits, wall slides in a standing
position ,mini squats and partial lunges to develop control of the knee extensors and reduce
the risk of an extensor lag.
Regular exercise to restore strength and mobility to your knee and a gradual return to
everyday activities are important for your full recovery after knee replacement. Your
orthopaedic surgeon and physical therapist may recommend that you exercise for 20 to 30
minutes, 2 or 3 times a day and walk for 30 minutes, 2 or 3 times a day during your early
recovery. They may suggest some of the exercises shown below,

Early Postoperative Exercises

The following exercises will help increase circulation to your legs and feet, which is
important for preventing blood clots. They will also help strengthen your muscles and
improve knee movement.

DAY OF SURGERY
Ankle toe pumps
*Ankle pumping exercises with the leg elevated immediately after surgery to prevent DVT

* Ice for 20 minutes every 1-2 hours.

* CPM 0-100° started in Recovery Room for minimum of 4 hours.
* A towel roll should be placed under the ankle when the CPM is not in use.
POD 1
* Increase CPM approximately 10° (more if tolerated). Continue daily until patient
achieves 100° of active knee flexion.
* Ice involved knee for 15 minutes for minimum of 3 times per day.
* Review and perform all bedside exercises which include
* ankle pumps

* Quadriceps sets-
Place a small rolled towel just above your heel so that your heel is not touching the bed.
Tighten your thigh. Try to fully straighten your knee and to touch the back of your knee to
the bed. Hold fully straightened for 5 to 10 seconds.

*HEEL SLIDES
Slide your foot toward your buttocks, bending your knee and keeping your heel on the bed.
Hold your knee in a maximally bent position for 5 to 10 seconds and then straighten.

* Sit at the edge of bed with necessary assistance.

* Sit in a chair for 15 minutes.
* Actively move knee 0-70°.
*Straight leg raise
Tighten your thigh muscle (quad) with your knee FULLY straightened on the bed. As your
thigh muscle tightens, lift your leg 30 cm off the bed. Hold for 5 seconds.

*Quads in sitting position

Sitting well back on the bed or the chair, pull your toes up and straighten your knee.
Hold for a count of 5, then slowly lower.
Do one set of 10 repetitions with each leg, 3 times a day.

* Ambulate with standard walker with moderate assistance. Stand comfortably and erect
with your weight evenly balanced on your walker. Advance your walker short distance;
then reach forward with your operated leg with your knee straightened so the heel of your
foot touches the floor first. As you move forward, your knee and ankle will bend and your
entire foot will rest evenly on the floor. As you complete the step, your toe will lift off the
floor and your knee and hip will bend so that you can reach forward for your next step.
Remember, touch your heel first, then flatten your foot, then lift your toes off the floor.

POD #2
• Continue as above with emphasis on improving ROM, performing proper gait pattern
with assistant device, decreasing pain and swelling, and promoting independence with
functional activities.
• Perform bed exercises independently 5 times per day.all exercises mentioned above.
• Perform bed mobility and transfers with minimum assistance.
• Ambulate with standard walker
• Ambulate to the bathroom and review toilet transfers.
TOILET TRAINING
patient will use a raised toilet seat and armrests or a commode. Be sure that when you are
seated, the toilet paper is within easy reach.
Back up until you can feel the toilet with the back of your legs.
Slide your operated leg forward.
Grasp the armrests and bend your knees. Lower yourself gently onto the toilet.
To stand up, reverse the procedure.

• Sit in a chair for 30 minutes twice per day, in addition to all meals.
• Actively move knee 0-80°.

POD #3
• Continue as above.
• Perform bed mobility and transfers with contact guarding.
• Ambulate with standard walker with supervision.
• Begin standing hip flexion and knee flexion exercises.
• Sit in a chair for most of the day, including all meals. Limit sitting to 45 minutes in a
single session.
• Use bathroom with assistance for all toileting needs.
• Actively move knee 0-90°.

POD #4
• Continue as above.
• Perform bed mobility and transfers independently.
• Ambulate with distant supervision.
• Negotiate 4-8 steps with necessary assistance.
• Continue to sit in chair for all meals and most of the day. Be sure to stand and stretch
your operated leg every 45 minutes.
• Actively move knee 0-95°.
• Discharge from the hospital to home if ambulating and negotiating stairs
independently.

POD #5
• Continue as above.
• Perform bed mobility and transfers independently.
• Perform HEP independently.
• Actively move knee 0-100°.
• Discharge from the hospital to home.

PHASE II: PROGRESSIVE FUNCTION (WEEKS 2-5)

Goals:
1. Progress from Walker to straight cane.
2. Improve involved lower extremity strength and proprioception.
3. Improve static and dynamic balance to good-normal.
4. Maximize function in the home environment.
5. Attain 0-125° active knee motion.
Weeks 2-3
• Monitor incision site and swelling.
• Continue with HEP.
• Progress ambulation distance (increase 1/2 block to 1 block each day) with WBQC.
• Begin stationary bicycle with supervision for 5-10 minutes.
• Begin standing wall slides. DO NOT ALLOW THE KNEES TO MOVE
FORWARD OF THE TOES.
• Incorporate static and dynamic balance exercises.
• AROM 0-115°.
WEEKS 3-4
• Continue as above.
• Practice with straight cane indoors.
• Increase stationary bicycle endurance to 10-12 minutes, twice per day.
• Attempt unilateral stance on the involved leg and side stepping.
• Incorporate gentle semi-squats (BODY WEIGHT ONLY) concentrating on eccentric
control of the quadriceps.

CLIMBING STAIRS
 GOING UP Leave the crutches down with the operated “bad” leg. Lift the non operated
“good” leg first onto the step Take your weight through your arms on the crutches. Then
step the operated “bad” leg and crutches last up onto the step.

WEEKS 4-5
• Continue as above.
• Ambulate with straight cane only.
• Increase stationary bicycle to 15 minutes, twice per day. This is an excellent activity to
help you regain muscle strength and knee mobility. At first, adjust the seat height so that
the bottom of your foot just touches the pedal with your knee almost straight. Peddle
backwards at first. Ride forward only after a comfortable cycling motion is possible
backwards. As you become stronger (at about 4 to 6 weeks) slowly increase the tension on
the exercycle. Exercycle for 10 to 15 minutes twice a day, gradually build up to 20 to 30
minutes, 3 or 4 times a week.
• Progress with gentle lateral exercises, i.e. lateral stepping, carioca.
• Attain AROM 0-125°.

PHASE III: ADVANCED FUNCTION (WEEKS 6-8)

Goals:
1. Progress to ambulating without an assistive device.
2. Improve static and dynamic balance to normal without assistive device.
3. Attain full AROM (0-135°).
4. Master functional tasks within the home environment.

WEEKS 6-7
• Continue as above.
• Ambulate indoors WITHOUT device..
• Focus on unilateral balance activities.
• Continue aggressive AROM exercise to promote knee range of motion 0-135°

WEEKS 7-8
• Continue as above.
• Develop and instruct patient on advance exercise program for continued strength and
endurance training.
• Ambulate without straight cane.
RISKS AND COMPLICATIONS OF TKR

*Complications from anesthesia

A surgeon may use general or regional anesthesia to put you into a deep sleep or numb
your leg. This is so you won’t feel any pain during surgery. Modern anesthesia is generally
safe, but it can cause side effects and negative reactions. It can be fatal in some rare cases.
The most common side effects include:

vomiting
dizziness
shivering
sore throat
aches and pains
discomfort
The general anesthesia may also cause an irregular heartbeat in some people.

*Blood clots
The medical term for blood clots when they occur in the legs is deep vein thrombosis
(DVT). Clots in the lungs are called pulmonary embolism (PE). Surgery or an injury of any
kind increases the risk of a blood clot. That’s because the clotting process is stimulated as
your body attempts to stop the bleeding and close the surgical wound. A clot is normally
formed by blood cells and clotting factors working together to create a protective scab over
a healing wound. The surgical procedure may stimulate clots to form in error in blood
vessels, which then may block the normal flow of blood.

Orthopedic surgeries like knee replacements are particularly likely to cause blood clots.
Blood clots typically occur within two weeks of surgery, but they can also take place within
a few hours or even in the operating room. Clots caused by DVT could delay your release
from the hospital by a few.
Clots contained in the legs are a relatively minor risk. However, a clot that dislodges and
travels through the body to the heart or lungs can cause serious health concerns. It can be
fatal in rare cases. There are a few preventative measures that you and your doctor can
discuss:
Blood thinning medications. Your doctor will likely recommend that you take medications
like warfarin (Coumadin), heparin, enoxaparin (Lovenox), fondaparinux (Arixtra), or
aspirin to reduce the risk of clots after surgery. Talk with your doctor to understand any
side effects caused by these medications.
Techniques to improve circulation. Your doctor may suggest treatments like support
stockings, lower leg exercises, calf pumps, or elevating your legs to help increase circulation
and prevent clots from forming.
Be sure you discuss your risk factors for clots before your surgery. Some conditions, such
as smoking or obesity, increase your risk.

Finally, talk to your surgeon about the signs and symptoms of a blood clot so you can
monitor yourself after you leave the hospital. The AHRQ provides additional information
on the prevention, symptoms, and treatment of blood clots.

*Infection
The number of people who get an infection after a knee replacement is very low (rates for
computer-assisted surgery are even lower). According to Healthline’s analysis of Medicare
and private pay claims data, 1.8 percent of patients are reported to develop an infection
within 90 days of surgery.
Because the knee joint is exposed during the procedure, the surgical team takes serious
measures to prevent infections:
Hospitals typically use special air filters for surgical rooms that limit particles in the air.
Surgeons and their assistants follow a strict procedure of “scrubbing in” and dressing in
protective wear in order to meet sterility standards of the operating room.
The surgical instruments and the implants themselves are all sterilized before they enter
the operating room.
Your doctor will also likely prescribe antibiotics before, during, and after the operation to
help prevent infection.
People with rheumatoid arthritis or diabetes have a greater risk of infection in the weeks
following a procedure. Researchers believe they have higher complication and mortality
rates because of their altered immune system.

Also keep in mind that if you have an infection in another part of the body at the time of
your knee operation — in your mouth, kidneys, or prostate, for example — it could lead to
an infection in your knee months or even years later. Talk with your doctor if you’ve
recently had or plan to have any other medical procedures within a few months of your
TKR.

*Complications from a transfusion

On occasion, a blood transfusion is necessary following the TKR procedure. If you receive
a blood transfusion, there’s a tiny risk that you will become sick due to an incompatible
blood match during a transfusion.

Blood banks routinely screen for all potential infections and illnesses, including AIDS and
hepatitis B and C. In extremely rare cases, however, these conditions go undetected.

It’s possible to have an allergic reaction or a reaction called a hemolytic transfusion

reaction to the donor blood, although this is also rare.
Signs and symptoms of an adverse transfusion reaction usually occur within 24 hours.
Symptoms of these reactions include:
hives
fever
chills
shortness of breath
red urine
Some hospitals ask you to bank your own blood before surgery. Ask whether it’s advisable
to bank your own blood in advance if your surgeon thinks you might need blood during
surgery.

*Allergy to metal components

Some people may suffer a reaction to the metal used in the artificial knee joint. The metal
materials used in implants are typically made from titanium or cobalt-chromium-based
alloy. You probably already know if you have a metal allergy. If so, make sure to tell your
surgeon about the allergy well before your surgery. Take the time to discuss the topic with
your surgeon or medical team if you are unsure.
*Wound and bleeding complication
The sutures or staples used to close the wound are typically removed after about two
weeks. There are some potential complications, however:
Wounds may sometimes be slow to heal and bleeding complications can occur for several
days following surgery. The hospital staff will monitor your wound during the time you are
there. Blood thinners can contribute to problems. The surgeon might need to reopen the
wound and drain fluid.
You could also experience a Baker’s cyst, which is a buildup of fluid behind the knee. This
may require draining with a needle to remove the fluid.
If the skin does not heal properly, you might need a skin graft.
*Artery injuries
Because the major arteries of the leg are directly behind the knee, there’s a slight risk that
these vessels could be damaged. A vascular surgeon can usually repair the arteries if there
is damage.

*Nerve or neurovascular damage

It’s also uncommon for the nerves to be damaged. However, it’s possible for the nerve or
blood vessel that’s associated with the muscles leading to the foot to feel numb afterward.
The problem usually disappears after a few months as nerves and tissue heal.

*Knee stiffness and loss of motion in the knee

Scar tissue or other complications can sometimes affect motion in the knee. This problem
can often be resolved with special exercises or physical therapy. Severe cases of stiffness,
called arthrofibrosis, may require a follow-up procedure so the scar tissue can be broken
up or the prosthesis inside the knee can be adjusted.

*Prosthesis problems and implant failure

Another risk with any joint replacement surgery is improper placement or a malfunction
of the implant. For example, the artificial kneecap may not track correctly after surgery —
in other words, your new knee might not bend properly.Another possible implant problem
is that the prosthesis might loosen from the bone over the long term. It will require an
adjustment if that happens.Other parts in the artificial knee can also wear or break,
including the polyethylene components.
 REFERENCES

*tkr+rehabilitation&rlz=1C1EJFC_enIN804IN804&oq=TKR&aqs=chrome.1
.69i57j69i59l3.3395j0j7&sourceid=chrome&ie=UTF-8
*Textbook orthopaedics by ebnezar
*https://www.healthline.com/health/total-knee-replacement-
surgery/rehabilitation-timeline
*https://www.physio-pedia.com/Total_knee_arthroplasty