Total Knee Arthroplasty - Total Knee Replacement Physiotherapy in Gurgaon
Total Knee Arthroplasty
The total knee arthroplasty is indicated when there is unremitting severe pain the knee with or with deformity. The pain or deformity may be due to primary or secondary, RA, and various other often non specific arthritides. It relieves the pain, provides mobility and corrects deformity.
The total knee replacement can be
- UNICOMPARTMENTAL ARTHROPLASTY: The articular surfaces of the femur and tibia of the either the medial or the lateral compartment of the knee are replaced by an implant. The other compartment of the knee joint is left intact. This type is obviously indicated for the disease pertaining to one compartment only e.g. OA. This procedure however has almost become obsolete due to its long term poor results.
- BICOMPARTMENTAL: In this the articular surface of tibia and femur of the both medial and lateral compartments of the knee joint are replaced by an implant. The third compartment i.e. patellofemoral joint is however left intact. It is also discarded due to its high failure.
- TRICOMPARTMENTAL ARTHROPLASTY: The articular surfaces of the lower femur, upper tibia and patella are replaced by prostheses. It is the most commonly performed arthroplasty. The prosthesis consists of a tibial component a metal femoral component and a HMWPE button for the articular surface of the patella.
- Postoperatively the knee is mobilized after 4 – 5 days.
Total Knee Replacement
Knee Replacement Physiotherapy Management
The principal aim of the physiotherapy is to offer maximum static as well as dynamic stability to the knee.
Severe pain, instability of the joint or deformity which cannot be corrected by osteomy is the chief indication foot the TKR.
Have You Suffered From Knee Pain ?
Pre Operative Assessment Summary
- Degree of Pain is Accessed
- The degree of deformity is measured
- Patellar mobility is also checked and graded
- Strength and endurance of quadriceps hamstring and glutei are evaluated
A thorough assessment is done prior to the surgery and the postoperative regimen physiotherapy is explained to the patient.
Pain: The degree site and the position aggravating /relieving the pain are recorded
Deformity: The degree of deformity is measured in weight bearing positions. The degree of deformity is recorded when the whole body weight is borne over the affected knee alone, may be some support is required.
ROM: Accurate measurements of the active as well as passive ROM at the knee are recorded. Patellar mobility is also checked and graded. Ligamentous stability around the knee is evaluated
Strength and endurance: Strength and endurance of quadriceps hamstring and glutei are evaluated. The quality of the quadriceps contraction needs to be assessed in particular
Effusion and atrophy: The area and the extent of the effusion as well as the muscle atrophy (especially the quadriceps) are recommended.
The other related joints i.e. hip, ankle and foot are assessed for their alignment Rom and strength.
Complete gait analysis, status of ambulation and functional competence are documented.
Physical requirements of the patient’s working situation are reviewed.
It includes the following:
- Explain to the patient the total post operative regimen and his responsibility. Biomechanics of the movements at the knee to be explained on the normal knee and the importance of regaining early ROM at the knee is emphasized.
- Educate the patient on the measures taken for the prevention of edema, deep venous thrombosis and chest complication.
- Training of isometrics (speedy as well as sustained) to quadriceps, hamstring and glutei.
- Self assisted passive mobilization relaxed free movements and assisted active and resistive exercises are taught on the sound limb
- Techniques of self assisted mobilization and strengthening are explained.
Post Operative Regieme
General outline or schedule for for Total Knee Replacement Physiotherapy
- Chest PT
- Vigorous toe and ankle movements
- Maintain the limb in extension
- Static glutei by pressing the pillow below the heel
- Gentle isometric to quadriceps
- Transfer to bed
- Gentle patellar mobilization
- Rapid isometrics to quadriceps ( speedy and with 10 sec hold)
- Assisted SLR
- Stand and ambulate with POP on and walker (WBTT for the cemented and TDWB or PWB for the non- cemented)
- Transfer in chair
- Self assisted passive knee flexion
- Heel drag in supine
- Bed side sitting relaxed knee movements with the help of sound leg ( in unilateral TKR)
- Sitting with the feet planted on the ground lift and push forward by raising trunk on arms.
- CPM 50- 100
NOTE: Range of knee flexion MUST NOY EXCEED 400 because transcutaneous 02 tension of the skin near the incision decreases significantly after 40 degree of flexion.
- Begin active or active assisted exercises
- Bed side knee flexion –extension
- Ambulation without POP
Day 7- 10
- Work up towards 90 knee flexion by 10 m-14 days.
- Hamstring strengthening
- Assisted step and stairs.
Day 11- 3 weeks : progress all exercises
- Work up towards knee flexion 1100-1150
- Quadriceps dips and steps up
- Stationary bicycle
- TWB with cane
- Appropriate chest physiotherapy
- Limb positioning to avoid rotation and to encourage knee extension .Ideally the heel resting on a pillow and pressing the pillow will encourage static quadriceps and gluteus maximus contraction along with extension stretch to knee.
- Gentle isometrics to the quadriceps could be begun. It should be progressed to rthymic speedy quadriceps contraction and relaxations which will promote patellar excursion and reduce edema.
- Sustained isometrics to the quadriceps reinforced by simultaneous strong dorsiflexion of the ankle are ideal. Slow isometrics should follow the rule of ‘TENS” i.e. holding maximum contractions for 10 seconds to be done 10 times in each session and each exercises session to be done 10 times a day.
- Isometrics to hamstring, gleutei and hip abductors should also be included.
- Supported SLR could be initiated with simultaneous isometrics to quadriceps and ankle in maximum dorsiflexion.
- Bed transfer standing or even well assisted ambulation with walker could be attempted by 3rd and 4th postoperative day. For cemented prosthesis weight bearing toe tolerance (WBTT) or PWB can be initiated while toe down weight is done for non cemented TKR.
- The patient should be educated on relaxed self assisted passive knee flexion –extension in small range or CPM with a speed of one cycle per minute.
- If the wound is dry and clean assisted active or active knee mobilization can be begun.
- SLR should be made intensive by slow speed SLRS with self generated tension in the quadriceps without relaxation in between SLRS.
- Intensify relaxed passive and assisted active knee flexion exercises by this time the range of knee flexion should reach 90 degree or close to I t.
- Once three independent SLRS against gravity in supine are achieved, ambulation without immobilization can be begun.
- Weight transfer and PWB on the operated limb may be begun on crutches.
3 to 6 weeks
- Work up to achieve knee flexion close to 110- 115
- Single crutch walking and well assisted stair activities should be introduced.
- Sessions on ped –o- cycle or even stationary bicycle should be begun
- Gait training with emphasis on free knee swinging be started with a cane and progressed from PWB to total weight bearing
- Hydrotherapy or pool exercises are ideal at this stage
- Quadriceps dips and step and stairs in normal pattern could be initiated with assistance.
6 weeks onwards
The patients gait with cane should be assessed for any deviation also ensure that both the tibio femoral compartments of the prosthesis are loaded evenly and not like a normal knee joint where the loading is predominately medial
Cane should be discarded by assuring normal gait pattern and the degree of stress during job requirements by 12 weeks.