Group 1 - Knee osteoarthritis and replacement

What is a classic history or capsule summary for this presentation? Specifically a typical mechanism of
injury and the typical aggravating and relieving factors.

In CG59 (2008) the GDG considered the following to represent a clinician’s working diagnosis of
peripheral joint osteoarthritis:

 persistent joint pain that is worse with use

 age 45 years old and over
 morning stiffness lasting no more than half an hour.

Classic Presentation
The patient with osteoarthritis (OA) complains of stiffness and knee pain that is worse with prolonged
sitting or walking. She or he is generally older or has a past history of trauma or surgery to the knee.
Recurrent bouts of mild swelling and a progressive bowlegged appearance may be accompanying
complaints.

Cause
Degeneration of articular cartilage is often secondary to meniscal tearing or degeneration. This occurs
with age. Often significant, single trauma events or a past knee surgery (including ACL or meniscal
surgeries) predispose the individual to early degeneration.

Indications for Surgery

The following are common indications for TKA.

■ Severe joint pain with weight bearing or motion that compromises functional abilities
■ Extensive destruction of articular cartilage of the knee secondary to advanced arthritis

■ Marked deformity of the knee such as genu varum or valgum

■ Gross instability or limitation of motion

■ Failure of nonoperative management or a previous surgical procedure

Complications
Overall, the incidence of complications after TKA is low. Intraoperative complications during knee
arthroplasty, such as an intercondylar fracture or damage to a peripheral nerve
(e.g., the peroneal nerve), are uncommon. Because minimally invasive TKA is considered more
technically challenging than conventional TKA, early reports suggest that the rate of intraoperative
complications, such as fracture or malpositioning of an implant, is higher with a minimally invasive than a
standard approach. An increased incidence of intraoperative technical errors, which can affect outcomes,
is associated with patient obesity.

Early and late postoperative complications include infection, joint instability, polyethylene wear, and
component loosening. As with arthroplasty of other joints, there is a risk of wound-healing problems and
deep vein thrombosis (DVT) during the first few months after surgery. Although the incidence of deep
periprosthetic infection is low, it is the most common reason for early failure and the need for revision
arthroplasty. In contrast, polyethylene wear of the patellar and tibial components is the most common late
complication requiring revision. Other postoperative complications that can compromise a patient’s
functional recovery include limited knee flexion, joint instability leading to subluxation, and patellar
instability or tracking problems leading to impaired function of the extensor mechanism (most often an
extensor lag). Additionally, obesity has been shown to limit outcomes in a patient’s mobility after TKA
compared to nonobese patients.

What red flags and other conditions you need to eliminate? (include systemic and peripheral
presentations).

Red flags in history that may indicate further investigation or referral

 Progressive, well-localised pain that does not vary with activity, posture or time of day
 Pain worse at rest
 Pain significantly worse at night
 Prolonged morning stiffness > 2 hours
 Presence of co-morbid conditions that are associated with inflammatory arthritis eg psoriasis,
inflammatory bowel disease, diarrhoeal infections, STIs
 Presence of history or exam features suggesting connective tissue disease
 Persistent marked effusion

Red flags on clinical examination that may indicate further investigation or referral
 Pattern of joints affected
 Redness, calor, Swelling, Tenderness, Deformity (Calor, dolor, rubor, and tumor: Heat, pain,
redness, and swelling.)
 Significant loss of range of movement or locked joint
 Unexplained mass or swelling
 Weakness, wasting, numbness, loss of reflexes or hyperreflexia
 Loss of peripheral pulses
 Skin rashes
 Temporal artery tenderness
 Pain not reproduced by usual movement during examination (cancer)
 Instability of joint (soft tissue trauma)
 Lymphadenopathy

Possible serious underlying pathologies

 Infection
 Cancer
 Fracture
 Crystal arthropathy
 Soft Tissue Trauma and Peri-articular Disorders
 Inflammatory Disorders
 Vascular Disorders (e.g. claudicant pain)
 Neurological Disorders (e.g. radiculopathy or neuropathic pain)
 Referred pain from adjacent joints and structures

What outcome assessments would you use?

■ Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

■ Knee injury and Osteoarthritis Outcome Score (KOOS) https://www.orthotoolkit.com/koos/

■ Lysholm Knee Scoring Scale - is commonly used as a subjective report scoring system designed to
evaluate the intervention outcome and postsurgical result of knee patients.
 If there is a grading scale, can you briefly describe it?

Radiological findings - Classification

Numerous variations of the Kellgren and Lawrence classification system have been used in research.
Below is the original description:

grade 0 (none): definite absence of x-ray changes of osteoarthritis

grade 1 (doubtful): doubtful joint space narrowing and possible osteophytic lipping

grade 2 (minimal): definite osteophytes and possible joint space narrowing

grade 3 (moderate): moderate multiple osteophytes, definite narrowing of joint space and some
sclerosis and possible deformity of bone ends

grade 4 (severe): large osteophytes, marked narrowing of joint space, severe sclerosis and definite
deformity of bone ends

Osteoarthritis is deemed present at grade 2 although of minimal severity

Primary knee osteoarthritis

- Degeneration of the knee cartilage due to an unknown reason, such as general age-related
articular degeneration
Secondary knee osteoarthritis
- Degeneration of the knee cartilage due to a known reason
o Post trauma, post-surgical, congenital, scoliosis, rickets, hemochromatosis,
chondrocalcinosis, ochronosis, Wilson disease, gout, pseudo gout, acromegaly, AVN,
RA, infectious arthritis, PA, haemophilia, Paget disease, sickle cell disease.

What imaging techniques would you use and why?

X-ray - weight-bearing 45-degree P-A flexion. Radiographic imaging is required. Recommended series
include:
 - Standing A-P
- Standing Lateral in extension
- Skyline patella
- Standing 45˚ P-A
This standing series is necessary to view appropriate joint space changes.

Magnetic resonance imaging (MRI) is a commonly ordered investigation in patients who present with
knee conditions. However, most of the information required for decision-making in patients with knee OA
can be gathered from a proper history, physical examination, and the aforementioned radiographs.

On the provided Images, please indicate the pathology and describe it?

Before surgery;
 Narrowed joint space – completely reduced on medial aspect
 Subchondral sclerosis
 Osteopenia – trabeculae visible

After knee replacement;

  Symmetrical joint space restored
 Lining placed on inner patella surface
What relevant orthopaedic, quantitative and qualitative tests would you use? Demonstrate one of
each on the patient to the class.

 Lower Extremity Function Scale https://www.orthotoolkit.com/lefs/

 Aggregated Locomotor Function Score
 Single leg hop test
 Single leg squat
 Knee Outcome Survey https://www.orthotoolkit.com/kos/

Outline your management strategy including chiropractic and other techniques, treatment plan;
including your visit schedule, home advice, exercises and progressions. Include expectations of what
they can achieve at relevant time frames and what exercises you would use in the relevant time
frames.

Management plan for knee replacement

Week 1
• Goals
– Able to bend knee to 90 degrees
– Able to fully straighten the knee
– Lift the straight leg off the bed
– Walk independently and manage stairs
– Confident to manage at home

• Exercises
– Isometric contractions to high load.
– Rom exercises of the knee (gently)
– Usually still bandaged /taped so careful with rom
– Start to focus on equal/symmetrical gait pattern (even at this early stage)

Week 2
• Goals
– Bandages off
– Clean looking scar
– Swelling reducing
– Progressing to single crutch (if managed well)

• Exercises
– Hip hinge mechanism
– Using total hip machine focus on quad and glut strength
– Alternate, use theraband attached above the knee
– Isolation exercises
– Heel sliders

• Considerations
– Look out for infection
– Knee will still be hot
– Make sure they are progressing, address fears and concerns
Week 3-4
• Goals
– Knee flexion over 90 degrees
– Start to GENTLY mobilise scar
– Address tension, dysfunction in hams and calf
– Effective glut and quad activation
– Off the crutches

• Exercises
– Hip hinges/squats going well.
– Heel toe glides
– Heel toe rocking
– Symmetrical walking
– Heel sliders with resistance
– Isolation exercises on machines for hams, quads, calf

Week 4-6
• Goals
– Should be at 100-120 degrees flexion
– Walking without assistance or crutches
– Gait symmetrical and pain free
– Able to walk up stairs
– Potentially able to ride an exercise bike
– Swelling almost resolved

• Exercises
– Squats
– Exercises bike
– Rower
– Functional lunge
– Getting into and out of chairs/toilets etc

• Considerations
– Scar release work
– Stretch quads and hams

Week 4-6
• Goals
– Should be at 100-120 degrees flexion
– Walking without assistance or crutches
– Gait symmetrical and pain free
– Able to walk up stairs
– Potentially able to ride an exercise bike
– Swelling almost resolved

• Exercises
– Squats
– Exercises bike
– Rower
– Functional lunge
– Getting into and out of chairs/toilets etc
– Step ups and steps downs

• Considerations
– Scar release work
– Stretch quads and hams

6weeks – 3 Months
• Goals
– Knee flexion greater than 120 degrees
– Swelling normal
– No heat in knee
– Normal gait

• Exercises
– Functional integration of movement patterns and exercises

• Considerations
– If rom is not normal, consideration of reimaging
– Communication with surgeon as to progress forges relationships
– Make sure your communication is concise and accurate
Recommendations for Participation in Physical Activities Following TKA

Highly Recommended*

■ Stationary cycling
■ Swimming, water aerobics
■ Walking
■ Golf (preferably with golf cart)
■ Ballroom or square dancing
■ Table tennis

Recommended If Experienced Before TKA**

■ Road cycling
■ Speed/power walking
■ Low-impact aerobics
■ Cross-country skiing (machine or outdoor)
■ Table tennis
■ Doubles tennis
■ Rowing
■ Bowling, canoeing

Not Recommended***

■ Jogging, running
■ Basketball
■ Volleyball
■ Singles tennis
■ Baseball, softball
■ High-impact aerobics
■ Stair-climbing machine
■ Handball, racquetball, squash
■ Football, soccer
■ Gymnastics, tumbling
■ Water-skiing

*Low impact, low-load; appropriate at moderate- or high-intensity on a regular basis for

aerobic fitness.
**Moderate impact; appropriate on a recreational basis if performed at low or moderate
intensity.
***High impact, high load; peak load occurs during knee flexion.