Total Knee Arthroplasty: Difference between revisions
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== Definition/Description == | == Definition/Description == | ||
Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee joint ( the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.<ref> | Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the [[Knee|knee joint]] (the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the [[tibia]] and the [[femur]], as a shock absorber.<ref>Medscape. Total knee arthroplasty (TKA). Available from: https://emedicine.medscape.com/article/1250275-overview#:~:text=The%20primary%20indication%20for%20total,pain%20caused%20by%20severe%20arthritis. (accessed 28/07/2020).</ref> In 50% of the cases the [[patella]] is also replaced. Reasons for a patella replacement include: osteolysis, maltracking of the patella, failure of the implant. The aim of the patella reconstruction is to restore the extensor mechanism. The level of bone loss will dictate which kind of patella prosthesis is placed. | ||
{{#ev:youtube|https://www.youtube.com/watch?v=EV6a995pyYk|width}}<ref>Nucleus Medicine Media. Total Knee replacement surgery. Available from: https://www.youtube.com/watch?v=EV6a995pyYk (last accessed 3.3.2019)</ref> | {{#ev:youtube|https://www.youtube.com/watch?v=EV6a995pyYk|width}}<ref>Nucleus Medicine Media. Total Knee replacement surgery. Available from: https://www.youtube.com/watch?v=EV6a995pyYk (last accessed 3.3.2019)</ref> | ||
The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function | The main clinical reason for the operation is [[Knee Osteoarthritis|osteoarthritis]] with the goal of reducing an individuals pain and increasing function.<ref>Kloiber J, Goldenitsch E, Ritschl P. [https://pubmed.ncbi.nlm.nih.gov/27142969/ Patellar bone deficiency in revision total knee arthroplasty.] Der Orthopade 2016;45(5):433.</ref> | ||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
[[Image:Structures of the knee.png|right|300x300px|The most important structures of the knee]] The [[Knee]] is a modified [[Joint Classification|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 tibial plateau, there is a meniscus, which adheres the tibia and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule. | [[Image:Structures of the knee.png|right|300x300px|The most important structures of the knee]] The [[Knee]] is a modified [[Joint Classification|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 tibial plateau, there is a meniscus, which adheres the [[tibia]] and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule. | ||
== Epidemiology /Etiology == | == Epidemiology /Etiology == | ||
When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is [[Osteoarthritis]] <ref name="Skou et al.">Skou ST, Graven‐Nielsen T, Rasmussen S, Simonsen OH, Laursen MB, Arendt‐Nielsen L. Facilitation of pain sensitization in knee osteoarthritis and persistent post‐operative pain: A cross‐sectional study. European Journal of Pain | When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is [[Knee Osteoarthritis|osteoarthritis]].<ref name="Skou et al.">Skou ST, Graven‐Nielsen T, Rasmussen S, Simonsen OH, Laursen MB, Arendt‐Nielsen L. [https://onlinelibrary.wiley.com/doi/abs/10.1002/j.1532-2149.2013.00447.x Facilitation of pain sensitization in knee osteoarthritis and persistent post‐operative pain: A cross‐sectional study.] European Journal of Pain 2014;18(7):1024-31.</ref> [[Knee Osteoarthritis|Osteoarthritis]] causes the cartilage of the joint to become damaged and no longer able to absorb shock. There are a lot of external risk factors that can cause knee osteoarthritis. For example: being overweight; previous knee injuries; partial removal of a meniscus;<ref name="Blagojevic et al." /> [[Rheumatoid Arthritis|rheumatoid arthritis]]; [[Fracture|fractures]]; congenital factors. There might also be some genetic factors the contribute to the development of [[osteoarthritis]], but more research is necessary. Total knee arthroplasty is more commonly performed on women and incidence increases with age.<ref name="Blagojevic et al.">Blagojevic M, Jinks C, Jeffery A, Jordan 1. [https://www.sciencedirect.com/science/article/pii/S1063458409002258 Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.] Osteoarthritis and cartilage 2010;18(1):24-33.</ref> IN the US in 2008 63% of TKR operations were on women. Also a dramatic increase in TKR surgery is projected to occur with a 673% increase by 2030 in America.<ref name=":1">American Academy of Orthopaedic Surgeons. TKR surgery by the numbers. Available from: https://www.anationinmotion.org/value/total-knee-replacement-surgery-numbers/ (last accessed 03/03/2019).</ref> Another trend for TKR surgery is the increasing rate of of recipients under 60, whilst initially designed as an operation for the >70 age bracket.<ref>Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. [https://www.sciencedirect.com/science/article/abs/pii/S1521694212000976 The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007.] Best practice & research Clinical rheumatology 2012;26(5):637-47.</ref> | ||
== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods ( this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls. | Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods (this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls. | ||
=== Complications === | === Complications === | ||
Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.<ref>Etiology and | Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.<ref>Della Valle AG, Leali A, Haas S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504257/ Etiology and surgical interventions for stiff total knee replacements.] HSS Journal 2007;3(2):182-9.</ref> *0 5 of patients have some degree of movement limitation.<ref name=":1" /> In addition to stiffness, the following complications can impact on function following this surgery: | ||
* Loosening or fracture of the prosthesis components | * Loosening or fracture of the prosthesis components | ||
* Joint instability and dislocation | * Joint instability and dislocation | ||
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== Diagnostic Procedures == | == Diagnostic Procedures == | ||
In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered<ref>Lee, | In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered.<ref>Lee QJ, Mak WP, Wong YC. [https://journals.sagepub.com/doi/pdf/10.1177/230949901502300303 Risk factors for periprosthetic joint infection in total knee arthroplasty.] Journal of Orthopaedic Surgery 2015;23(3):282-6.</ref> Obesity is an important factor that needs to be considered prior to surgery as evidence suggests a correlation between higher body mass index (BMI) and poorer post-operative functional outcomes.<ref>Polat G, Ceylan HH, Sayar S, Kucukdurmaz F, Erdil M, Tuncay I. [[Effect of body mass index on functional outcomes following arthroplasty procedures.]] World journal of orthopedics 2015;6(11):991.</ref><br> | ||
[[Image:Stages Knee OA.jpg]] | [[Image:Stages Knee OA.jpg]] | ||
'' | ''Different stages of [[Knee Osteoarthritis|knee osteoarthritis]] on [[X-Rays|X-rays]]. '' | ||
== Outcome Measures == | == Outcome Measures == | ||
* Knee disability and Osteoarthritis Outcome score (KOOS) | * [https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0018/77031/knee-injury-and-osteoarthritis-outcome-score-koos1.pdf Knee disability and Osteoarthritis Outcome score (KOOS)] | ||
* | * [[Timed Up and Go Test (TUG)|Timed Get Up and Go Test (TUG)]] | ||
* Visual Analogue Scale (VAS) | * [[Visual Analogue Scale|Visual Analogue Scale (VAS)]] | ||
* Range of motion (ROM) <ref> | * Range of motion (ROM)<ref>Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. [https://link.springer.com/article/10.1186/s12891-015-0469-6 Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis.] BMC musculoskeletal disorders 2015;16(1):15. </ref> | ||
== Examination == | == Examination == | ||
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* Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor. | * Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor. | ||
* Palpation: post-operative swelling, hypertonia (adductors), pain and warmth. <u><ref name="Jakobsen and Linging et al.">Jakobsen, | * Palpation: post-operative swelling, hypertonia (adductors), pain and warmth.<u><ref name="Jakobsen and Linging et al.">Jakobsen TL, Kehlet H, Husted H, Petersen J, Bandholm T. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/acr.22405 Early progressive strength training to enhance recovery after fast‐track total knee arthroplasty: a randomized controlled trial.] Arthritis care & research 2014;66(12):1856-66.</ref></u> | ||
== Medical Management == | == Medical Management == | ||
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Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis. | Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis. | ||
During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.<ref>Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, Qiu G. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee. 2014; 21(6): 1263-1268</ref> | During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.<ref>Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, Qiu G. [https://www.sciencedirect.com/science/article/abs/pii/S0968016014001744 The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial.] Knee. 2014; 21(6): 1263-1268</ref> | ||
== | == Physiotherapy Management == | ||
=== Pre-operative === | === Pre-operative === | ||
The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.<ref>Huber EO, de Bie RA, Roos EM, Bischoff-Ferrari HA. Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial. BMC | The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.<ref>Huber EO, de Bie RA, Roos EM, Bischoff-Ferrari HA. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-14-157 Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial.] BMC musculoskeletal disorders 2013;14(1):1-8.</ref> | ||
Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.<ref> | Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.<ref>Kwok IH, Paton B, Haddad FS. [https://www.sciencedirect.com/science/article/pii/S0883540315002788 Does pre-operative physiotherapy improve outcomes in primary total knee arthroplasty?—a systematic review.] The Journal of arthroplasty 2015;30(9):1657-63. </ref> | ||
=== Post-operative === | === Post-operative === | ||
Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.<ref name=":0"> | Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.<ref name=":0">Henderson KG, Wallis JA, Snowdon DA. [https://www.sciencedirect.com/science/article/abs/pii/S0031940617300032 Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis.] Physiotherapy 2018;104(1):25-35. </ref> | ||
Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.<ref>Trzeciak T | Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.<ref>Trzeciak T, Richter M, Ruszkowski K. [https://europepmc.org/article/med/22708322 Effectiveness of continuous passive motion after total knee replacement.] Chirurgia narzadow ruchu i ortopedia polska 2011;76(6):345-9.</ref> The optimal physiotherapy protocol should also include strengthening and intensive functional exercises given through land-based or aquatic programs, that are progressed as the patient meets clinical and strength milestones. Due to the highly individualized characteristics of these exercises the therapy should be under supervision of of a trained physical therapist for best results.<ref>Husby VS, Foss OA, Husby OS, Winther SB. [https://europepmc.org/article/med/28901118 Randomized controlled trial of maximal strength training vs. standard rehabilitation following total knee arthroplasty.] European journal of physical and rehabilitation medicine 2018;54(3):371-9.</ref><ref>Schache MB, McClelland JA, Webster KE. [https://www.sciencedirect.com/science/article/abs/pii/S096801601300149X Lower limb strength following total knee arthroplasty: a systematic review.] The Knee 2014;21(1):12-20. </ref> | ||
There is evidence that cryotherapy improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of cryotherapy. | There is evidence that [[cryotherapy]] improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of [[cryotherapy]].<ref>Adie S, Kwan A, Naylor JM, Harris IA, Mittal R. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007911.pub2/abstract Cryotherapy following total knee replacement.] Cochrane Database of Systematic Reviews 2012(9). </ref> | ||
==== Common Bed and Chair Exercises ==== | ==== Common Bed and Chair Exercises ==== | ||
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<references /><br> | <references /><br> | ||
[[Category:Orthopaedic_Surgical_Procedures]] | [[Category:Orthopaedic_Surgical_Procedures]] | ||
[[Category:Knee]] [[Category:Knee - Interventions]] | [[Category:Knee]] | ||
[[Category:Knee - Interventions]] | |||
[[Category:Musculoskeletal/Orthopaedics]] | [[Category:Musculoskeletal/Orthopaedics]] | ||
[[Category:Vrije_Universiteit_Brussel_Project]] | [[Category:Vrije_Universiteit_Brussel_Project]] | ||
[[Category:Acute Care]] | [[Category:Acute Care]] | ||
[[Category:Older People/Geriatrics]][[Category:Older People/Geriatrics - Interventions]] | [[Category:Older People/Geriatrics]] | ||
[[Category:Older People/Geriatrics - Interventions]] | |||
[[Category:Interventions]] | [[Category:Interventions]] | ||
Revision as of 21:26, 28 July 2020
Original Editors - Lynn Wright
Top Contributors - Safiya Naz, Loes Verspecht, Kim Jackson, Kun Man Li, Lucinda hampton, Jess Bell, Ellen Wynant, Lisa Ingenito, Claire Knott, George Prudden, Karolien Van Melkebeke, Lynn Wright, Tarina van der Stockt, Lauren Lopez, Ewa Jaraczewska, Greg Walding, Daniele Barilla, WikiSysop, Karen Wilson, Famke Coosemans, Leana Louw, 127.0.0.1 and Evan Thomas
Definition/Description[edit | edit source]
Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee joint (the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.[1] In 50% of the cases the patella is also replaced. Reasons for a patella replacement include: osteolysis, maltracking of the patella, failure of the implant. The aim of the patella reconstruction is to restore the extensor mechanism. The level of bone loss will dictate which kind of patella prosthesis is placed.
The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function.[3]
Clinically Relevant Anatomy[edit | edit source]
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 tibial plateau, there is a meniscus, which adheres the tibia and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule.
Epidemiology /Etiology[edit | edit source]
When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is osteoarthritis.[4] Osteoarthritis causes the cartilage of the joint to become damaged and no longer able to absorb shock. There are a lot of external risk factors that can cause knee osteoarthritis. For example: being overweight; previous knee injuries; partial removal of a meniscus;[5] rheumatoid arthritis; fractures; congenital factors. There might also be some genetic factors the contribute to the development of osteoarthritis, but more research is necessary. Total knee arthroplasty is more commonly performed on women and incidence increases with age.[5] IN the US in 2008 63% of TKR operations were on women. Also a dramatic increase in TKR surgery is projected to occur with a 673% increase by 2030 in America.[6] Another trend for TKR surgery is the increasing rate of of recipients under 60, whilst initially designed as an operation for the >70 age bracket.[7]
Characteristics/Clinical Presentation[edit | edit source]
Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods (this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls.
Complications[edit | edit source]
Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.[8] *0 5 of patients have some degree of movement limitation.[6] In addition to stiffness, the following complications can impact on function following this surgery:
- Loosening or fracture of the prosthesis components
- Joint instability and dislocation
- Infection
- Component misalignment and breakdown
- Nerve damage
- Bone fracture (intra or post operatively)
- Swelling and joint pain
Complications as above may require joint revision surgery to be performed.
Diagnostic Procedures[edit | edit source]
In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered.[9] Obesity is an important factor that needs to be considered prior to surgery as evidence suggests a correlation between higher body mass index (BMI) and poorer post-operative functional outcomes.[10]
Different stages of knee osteoarthritis on X-rays.
Outcome Measures[edit | edit source]
- Knee disability and Osteoarthritis Outcome score (KOOS)
- Timed Get Up and Go Test (TUG)
- Visual Analogue Scale (VAS)
- Range of motion (ROM)[11]
Examination[edit | edit source]
Subjective Assessment[edit | edit source]
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
Post-operative Tests[edit | edit source]
- Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor.
- Palpation: post-operative swelling, hypertonia (adductors), pain and warmth.[12]
Medical Management[edit | edit source]
The purpose of the surgical procedure is to achieve pain free movement again, with full functionality of the joint, and to recreate a stable joint with a full range of motion.
Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis.
During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.[13]
Physiotherapy Management[edit | edit source]
Pre-operative[edit | edit source]
The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.[14]
Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.[15]
Post-operative[edit | edit source]
Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.[16]
Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.[17] The optimal physiotherapy protocol should also include strengthening and intensive functional exercises given through land-based or aquatic programs, that are progressed as the patient meets clinical and strength milestones. Due to the highly individualized characteristics of these exercises the therapy should be under supervision of of a trained physical therapist for best results.[18][19]
There is evidence that cryotherapy improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of cryotherapy.[20]
Common Bed and Chair Exercises[edit | edit source]
- Ankle plantarflexion/dorsiflexion
- Isometric knee extension in outer range
- Inner Range Quadriceps strengthening using a pillow or rolled towel behind the knee
- Knee and hip flexion/extension
- Isometric buttock contraction
- Hip abduction/adduction
- Straight leg raises
- Bridging
References[edit | edit source]
- ↑ Medscape. Total knee arthroplasty (TKA). Available from: https://emedicine.medscape.com/article/1250275-overview#:~:text=The%20primary%20indication%20for%20total,pain%20caused%20by%20severe%20arthritis. (accessed 28/07/2020).
- ↑ Nucleus Medicine Media. Total Knee replacement surgery. Available from: https://www.youtube.com/watch?v=EV6a995pyYk (last accessed 3.3.2019)
- ↑ Kloiber J, Goldenitsch E, Ritschl P. Patellar bone deficiency in revision total knee arthroplasty. Der Orthopade 2016;45(5):433.
- ↑ Skou ST, Graven‐Nielsen T, Rasmussen S, Simonsen OH, Laursen MB, Arendt‐Nielsen L. Facilitation of pain sensitization in knee osteoarthritis and persistent post‐operative pain: A cross‐sectional study. European Journal of Pain 2014;18(7):1024-31.
- ↑ 5.0 5.1 Blagojevic M, Jinks C, Jeffery A, Jordan 1. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis and cartilage 2010;18(1):24-33.
- ↑ 6.0 6.1 American Academy of Orthopaedic Surgeons. TKR surgery by the numbers. Available from: https://www.anationinmotion.org/value/total-knee-replacement-surgery-numbers/ (last accessed 03/03/2019).
- ↑ Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best practice & research Clinical rheumatology 2012;26(5):637-47.
- ↑ Della Valle AG, Leali A, Haas S. Etiology and surgical interventions for stiff total knee replacements. HSS Journal 2007;3(2):182-9.
- ↑ Lee QJ, Mak WP, Wong YC. Risk factors for periprosthetic joint infection in total knee arthroplasty. Journal of Orthopaedic Surgery 2015;23(3):282-6.
- ↑ Polat G, Ceylan HH, Sayar S, Kucukdurmaz F, Erdil M, Tuncay I. Effect of body mass index on functional outcomes following arthroplasty procedures. World journal of orthopedics 2015;6(11):991.
- ↑ Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC musculoskeletal disorders 2015;16(1):15.
- ↑ Jakobsen TL, Kehlet H, Husted H, Petersen J, Bandholm T. Early progressive strength training to enhance recovery after fast‐track total knee arthroplasty: a randomized controlled trial. Arthritis care & research 2014;66(12):1856-66.
- ↑ Fan Y, Jin J, Sun Z, Li W, Lin J, Weng X, Qiu G. The limited use of a tourniquet during total knee arthroplasty: a randomized controlled trial. Knee. 2014; 21(6): 1263-1268
- ↑ Huber EO, de Bie RA, Roos EM, Bischoff-Ferrari HA. Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial. BMC musculoskeletal disorders 2013;14(1):1-8.
- ↑ Kwok IH, Paton B, Haddad FS. Does pre-operative physiotherapy improve outcomes in primary total knee arthroplasty?—a systematic review. The Journal of arthroplasty 2015;30(9):1657-63.
- ↑ Henderson KG, Wallis JA, Snowdon DA. Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis. Physiotherapy 2018;104(1):25-35.
- ↑ Trzeciak T, Richter M, Ruszkowski K. Effectiveness of continuous passive motion after total knee replacement. Chirurgia narzadow ruchu i ortopedia polska 2011;76(6):345-9.
- ↑ Husby VS, Foss OA, Husby OS, Winther SB. Randomized controlled trial of maximal strength training vs. standard rehabilitation following total knee arthroplasty. European journal of physical and rehabilitation medicine 2018;54(3):371-9.
- ↑ Schache MB, McClelland JA, Webster KE. Lower limb strength following total knee arthroplasty: a systematic review. The Knee 2014;21(1):12-20.
- ↑ Adie S, Kwan A, Naylor JM, Harris IA, Mittal R. Cryotherapy following total knee replacement. Cochrane Database of Systematic Reviews 2012(9).
- ↑ UnityPoint Health. Knee replacement exercise video. Available from:https://www.youtube.com/watch?v=nM0K5MlQc3U (last accessed 3.3.2019)
