TOTAL 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

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 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. Continue exercise programme (as day 1), add knee flexion (sliding) in sitting CPM if appropriate Ice therapy Day 3 onwards Exercise programme to increase range and strength of affected knee and maintain range and strength of both lower limbs (open and closed chain) Ice and elevation to control swelling Gait: assess and progress crutches, 1 or 2 sticks as appropriate Balance work Transfers: assess and progress to restore independence Step or stair practice Home exercise programme Attend Occupational Therapy Education Group when independently mobile Liase with other disciplines and family as necessary Refer for convalescence or community services as necessary CPM +/- NMT can be helpful with individual patients Discharge Criteria Independent with appropriate walking aid Independent with transfers Independent on steps/stairs if appropriate Effective with home exercise programme Able to control swelling with ice 0-90 active ROM or expected to achieve this independently

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Criteria for further out-patient follow up with TKR patients Poor bend (less than 80) and not improving and/or Poor quads strength (more than 15 lag) and not improving and/or Poor gait and/or Unusual circumstances e.g. drop foot, poor pain control, severe swelling, poor comprehension, poor compliance with exercises If possible, review in Cappagh. If not possible, refer to local outpatient physiotherapy service. Expected outcomes at 6 weeks Mobilising unaided around house and for increasing distances outdoors Decreasing pain and swelling, though not fully resolved. 0 to 110 degrees range of motion. Reasonable quadriceps and hamstring strength (4-5/5) Beginning to climb stairs normally. Able to perform light household activities, such as cooking, light polishing, sweeping floor. Able to swim if desired. Able to use ergometer and/or normal bike, if desired. 6-8 weeks onwards Review by their surgeon Wean off walking aids Advised to gradually return to normal activities such as driving, recreational walking, swimming, sexual activity. All activities should be within comfortable limits. Patients are invited to contact their physiotherapist if they have concerns or for advice regarding their progress. Expected outcomes at 6 months 1) Mobilising unaided for unlimited distances. 2) No pain or swelling. 3) 0 to 120 degrees range of motion. 4) Good lower limb strength (5/5). 5) Able to manage stairs and slopes easily 6) Able to kneel and do all normal household activities such as hoovering, washing. TKR surgery can give dramatic relief from pain and significant improvement in function BUT it is not a normal knee
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Return to Activities RED ALERT: Running, jogging, contact sports (soccer, rugby, GAA), jumping sports and high impact aerobics are considered dangerous activities that are not allowed after TKR. ORANGE ALERT: Vigorous walking or hiking, skiing, tennis, repetitive aerobic step climbing and repetitive lifts of greater than 50lbs are considered dangerous activities that should be avoided GREEN: Driving, recreational walking and light hiking, swimming, recreational cycling, golf and ballroom dancing are all activities that should be encouraged and introduced gradually after 6-8 weeks. Klein et al (2007)

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, DAntonio 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, OByrne JM (2008) Pre-operative quadriceps femoris neuromuscular electrical stimulation in patients undergoing total knee arthroplasty. Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital
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