Total Knee Replacement
eeTOTAL KNEE REPLACEMENT (T.K.R.) PHYSIOTHERAPY PROTOCOL PRE-OPERATIVE Patients should be evaluated prior to surgery, including: • Assessment of joint range of motion, muscle strength, mobility and general function • Respiratory assessment and treatment if necessary • Explanation of post-operative physiotherapy management, including respiratory and circulatory exercises • Teaching patient independence with bed mobility and transfers • Pre-operative activity and exercise programme to include quadriceps strengthening – there is evidence that this improves function post-operatively (McHugh et al, 2008) • Neuromuscular stimulation (NMT) if appropriate - there is evidence that this improve quadriceps function pre-operatively (Walls et al, 2008) • Education - pre-operative education can reduce anxiety and improve post-operative outcomes, especially with respect to pain, functioning and length of hospital stay (McDonald et al, 2007). In Cappagh this is achieved through attendance at a multi-disciplinary pre-assessment clinic. POST-OPERATIVE • Check operation notes and post-operative physiotherapy and mobility instructions. Day 1 • Assess respiratory status and treat if necessary • Encourage circulatory exercises • Correct position in bed – knee extended in Robert Jones bandage to minimise swelling (no pillows under knee). +/- heel raise. • Review bed transfers mobility
Physiotherapy January 2009
• Isometric exercises for quadriceps, hamstrings, gluteals +/- straight leg raises • CPM, if appropriate (remove bandages to apply) – there is some evidence that CPM combined with physiotherapy can produce small short-term increases in knee flexion, but no evidence that it influences pain, knee extension, long-term knee flexion, complications or length of stay (Milne et al, 2003, Grella, 2008) • Stand and mobilise with frame, if BP well controlled and power and sensation adequate on non-operated side Day 2 • Mobilise with frame, encouraging knee flexion in swing phase. •
Physiotherapy January 2009
• Isometric exercises for quadriceps, hamstrings, gluteals +/- straight leg raises • CPM, if appropriate (remove bandages to apply) – there is some evidence that CPM combined with physiotherapy can produce small short-term increases in knee flexion, but no evidence that it influences pain, knee extension, long-term knee flexion, complications or length of stay (Milne et al, 2003, Grella, 2008) • Stand and mobilise with frame, if BP well controlled and power and sensation adequate on non-operated side Day 2 • Mobilise with frame, encouraging knee flexion in swing phase. •
References: Grella RJ (2008) Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation? Physical Therapy Reviews 2008 aug; 13(4): 269-79 Klein GR, Levine BR, Hozack WJ, Strauss EJ, D’Antonio JA, Macauley W, Di Cesare PE (2007) Return to athletic activity after total hip arthroplasty. The Journal of Arthroplasty, 22(2), 2007 pp 171-175 McDonald S, Hetrick S, Green S (2004) Pre-operative education for hip or knee replacement. Australasian Cochrane Centre, Monash University, Australia McHugh G (2008) Pre-operative exercise for patients undergoing total knee replacement. Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G, Tugwell P (2008) Continuous passive motion following total knee arthroplasty. Cochrane Database of Systemic Reviews 2008 Issue 2 Walls RJ, McHugh G, Moyna NM, O’Byrne JM (2008) Pre-operative quadriceps femoris neuromuscular electrical stimulation in patients undergoing total knee arthroplasty. Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital Physiotherapy January 2009