Total Knee Replacement

Guided By : Dr. Kratika Varshney P.T.

Presented By : Harshita Sharma

BPT IV Yr
 CONTENTS

PART 03 PART 04 PART 05 PART 06

PART 01 PART 02

General Anatomy Muscles and Types of TKR Indications Contraindication

Definition
Ligaments
And
Epidemiology
 CONTENTS

PART 07 PART 08 PART 09 PART 10 PART 11 PART 12

Post-op Post-op Precautions Management

Recommendations Bibliography
Complication Physiotherapy of Rehab
for participation Problems after
in TKR
Long-term
Activities after TKR
 PART 01

Definition
Definition It is an orthopaedic surgical procedure
where the articular surfaces of the knee
joint {Femoral condyles and tibial plateau }
are replaced , to restore the function of
joint .
It is also known as Total knee Arthroplasty.
Epidemiology Knee replacements increases by 84 %
from 1997-2009 .

SEX : 37% are Male and 63% are Female

AGE : 18-44 years : 1.8%

45-64 years : 42%
65-84 years : 53.5%
85+ years : 2.6%

SUCCESS RATE : 9/10 people experience

dramatic pain relief
 PART 02

General Anatomy
 General Anatomy
Bones Forming Knee Joint : 1. Femur (lower part)
2. Tibia (upper part)
3. Patella
TYPE OF JOINT : Modified Hinge joint
Motion : Mainly Flexion and Extension
also slight amount of Internal and
External Rotation
It consist of : 1.Joint Capsule
2.Bursae
3. Cartilage
4. Menisci (articular disc )
 PART 03

Muscles and Ligaments

 MUSCLES OF KNEE JOINT
1. Flexors :
Sartorius Gastrocnemius
Biceps Femoris Plantaris
Semitendinosus Popliteus
Semimembranosus Gracilis

2. Extensors :
Articularis Genu
Quadriceps Femoris
Rectus Femoris
Vastus ( Lateralis , Intermedius and
Medialis)
LIGAMENTS OF KNEE JOINT
Intracapsular :
Anterior Cruciate lig.
Posterior Cruciate lig.
Transverse lig.
Meniscotibial lig.
Meniscofemoral lig.

Extracapsular :
Patellar lig.
Medial (tibial) Collateral lig.
Lateral (fibular) Collateral lig
 PART 04

Types of Total Knee Replacement

Types Of TKR
Unicompartmental Bicompartmental Tricompartmental
Unconstrained Semi-Constrained Constrained
Fixed bearing deign Mobile Bearing design
Standard traditional versus minimally invasive or quadriceps sparing
Cemented fixation Uncemented fixation
 PART 05

Indications
INDICATIONS
Generally, total knee arthroplasty (TKA) is
performed for Destruction of joint cartilage
either from :
Post-traumatic

GENERAL
Osteoarthritis Degenerative Joint Disease
INDICATIONS
Rheumatoid arthritis Osteonecrosis

Damage to the synovial

Inflammatory joint of one or more of
the three compartments.
arthritis
 OTHER INDICATIONS :

1. Severe knee pain that limits your everyday activities.

2. Moderate or severe knee pain while resting, day or night.
3. Long-lasting knee inflammation and swelling that doesn't get better
with rest or medications.
4. A bowing in or out of your leg.
5. No pain relief from NSAIDs or can't tolerate them.
6. Arthritis following fracture
7. Avascular necrosis
 PART 06

Contraindications
 Contraindications
Absolute Contraindications Relative Contraindications
1. Recent or current knee
1. Atherosclerotic disease
sepsis
of operative Leg
2. Source of ongoing
2. Bad skin condition within
Infection
operative field
3. Recurvatum deformity
3. Morbid Obesity
secondary to muscular
4. History of Osteomylitis
weakness
in the proximity of
4. Painful solid knee
the knee
fusion
 PART 07

Postoperative Complications
 Post-operative Complications
Stiffness is the most common complaint following primary total knee
replacement.
Some patients may have some degree of movement limitation.

In addition to stiffness, the following complications can

impact on function following this surgery:
1. Loosening or fracture of the prosthesis components
2. Joint instability and dislocation
Post-op Complications 3. Infection
4. Component misalignment and breakdown
5. Nerve damage
6. Bone fracture (intra or post operatively)
7. Swelling and joint pain
 PART 08

Postoperative Physiotherapy
 Post Operative Physical Therapy
Goals of Rehabilitation after Total Knee Arthroplasty are :

Prevent hazards of bedrest (e.g., DVT, pulmonary embolism,pressure ulcers)

Assist with adequate and functional ROM

Strengthen knee musculature

Assist patient in achieving functional independent activities of daily living

Independent Ambulation
 Rehabilitation Outline
【 Preoperative Physical Therapy】
• Review transfers with patient
• Bed-to-chair transfers.
• Bathroom transfers.
• Tub transfers with tub chair at home.
• Teach postoperative knee exercises
• Teach ambulation with assistive device
• Review precautions
B
E
D

M
O
B
I
L
I
T
Y
Bed to Chair Transfers
Bathroom Transfers
Tub Transfers
 Mnemonic
Good to Heaven
Bad to hell

Ambulation with assistive device

 Post - Operative Physiotherapy

0-90 degrees ROM in the first 2 wk before discharge from

an inpatient (hospital or rehabilitation unit) setting

Rapid mobilization to
【Inpatient Rehabilitation Goals】
Safety during ambulation
with walker and transfers minimize risks of bed rest

Rapid return of quadriceps control and strength to

enable patient to ambulate without knee immobilizer
 PHASE I : Immediate post-op Phase
(Days 0-10)
 Post-op compression dressing
Patient presentation :  ROM 10-60 degree

 Pain (0-10 scale/ VAS Scale)

 ROM
 Patellar Mobility
Examination :  Soft tissue palpation
 Muscle Control

 Control Swelling
 Knee flexion to 90 degree
Goals:  Minimising pain
 Early Ambulation witlh assistance device
 Quadriceps Strength : 3/5 or 4/5
 PHASE I : INTERVENTIONS
(DAY 0-3)
1. To Prevent vascular and Pulmonary Complication :
 Ankle pumping – with leg elevated to prevent venous
stasis and reduce risk of DVT or Pulmonary Embolism.
 Deep Breathing Exercise
2. To Control Pain and Swelling :
 Cold
 Compression
 Elevation
3. For Early Mobilisation :
Early weight bearing prefferably on the same day with the help
of walker.
 I
N
T
E
R
Ankle pumping V
Deeply breath in Slowly breath out
Deep Breathing Exercise E
N
T
I
O
Cold Compression Elevation
N
Early weight bearing S
 Continued….
4. To Regain Knee ROM -
1. Heel slides
2. CPM - • Do not allow more than 40 degrees of flexion on settings until
after 3 days
• 0-90 degrees as tolerated (4-8 days )
• Usually I cycle /min
• Progress 5 - 10 degrees a day as tolerated.
3. Gravity Assisted Knee Flexion by having patient sit and dangle the lower leg
over the side of the bed.
5. Exercises ( day 0-3 ) :
Initiate Isometrics ( hams and quads )
SLR ( Active assisted or active in supine and Prone position)
4.
Heel slides CPM Gravity Assisted Knee Flexion

5.
Isometrics quadriceps and hamstrings
SLR ( Active assisted or active in supine and Prone position)
 DAYS 4-10
5. Exercises :
 Ankle pumping
 Straight Leg Raise
 Continue Isometrics
 Short Arc Quadriceps (VMO)
 Passive knee Extension Stretch
 Hip abduction and adduction

6. To restablish Functional Mobility :

 Gait Training with assistive device
 Functional Training ( bed mobility , sit-to-stand transfers , basic ADLs)

7. To avoid Contracture : Patellar mobilization

8. To Improve Trunk Stability and Balance :
Balancing Activities in sitting and weight shifting in bilateral stance
 Hip abduction and adduction
Short Arc Quadriceps (VMO) Passive knee Extension Stretch

Patellar mobilization Weight shifting in

bilateral stance
 • Leg control, able to perform SLRs.
• Active ROM 0-90 degrees.
Patient presentation : • Minimal pain and swelling.
• Independent ambulation and transfers.

•Pain assessment
•Girth Measurement
Examination : •ROM
•Patellar Mobility
•Gait Analysis
 Continued…

Goals:

• Improve ROM by 110 degree or greater .

• Enhance muscular strength and endurance.
• Dynamic joint stability.
• Diminish swelling and inflammation.
• Establish return to functional activities.
• Improve general health
 PHASE II : INTERVENTIONS
1. To increase strength and endurance of knee musculature:
 Low –Intensity Dynamic Resistance Exercise of Quadriceps ,Hamstrings and Hip extensors,
abductors and adductors .
 Resisted SLRs
 Mini Squats
 Partial Lunges
 Sit to Stand
 Foreward and backward step ups and downs Progressing to lateral.
 Stationary cycling
 Cone-walking: progress from 4- to 6- to 8-inch cones.

2. To increase knee Range Of Motion :

 Stationary Cycling
 Prolonged stretching or hold relax technique for flexion and extension
 If Patellar mobility is restricting joint ROM – Grade III superior or inferior patellar mobilization
technique
 3. Exercises :
• Dynamic Quads
• Terminal knee extension 45-0 degrees (VMO )
• SLR (flexion-extension).
• Hip abduction-adduction.
• Hamstring curls.
• Squats.
• Stretching of Hamstrings ,Calf , Quadriceps muscles.
• Stationary Bicycle
• Continue passive knee extension stretch.
 Resisted SLRs

Mini Squats Partial Lunges Stationary Cycling

Cone Walking

Sit to Stand
 Dynamic Quads Hamstring Curls

Foreward and backward step ups and downs Progressing to lateral.

Quadriceps Stretch

Hamstring Stretch

Calf Stretch
 • ROM 0-110 degrees Knee Flexion and full Knee Extension
without Extension Lag.
• Voluntary quadriceps muscle control.
• Quadriceps / Hamstring muscle strength : 70-80%
Patient presentation : (4/5 MMT Grade ) compared to uninvolved leg
• Independent ambulation.
• Minimal to no pain and inflammation

• Pain Assesment
• MMT
Examination : • Gait Analysis
• Functional Status
• Patellar Alignment
 Continued…

Goals:

• Progression of ROM (0-115 degrees and greater).

• Enhancement of strength and endurance.
• Cardiovascular fitness.
• Functional activity performance and Community Ambulation
 PHASE III : INTERVENTIONS
1. Continue Phase II exercises with increasing repetitions and weight
2. To improve Balance and trunk stability :
 Trunk Stablization Exercise
 Bilateral to unilateral stance on stable surface then progress to unstable surface
 Functional Reaching Activities
 Tandem Walking, Grapevine walking (Initially in parallel bars for safety )
3. To improve Functional Mobility :
 Heel toe walking
 Ambulation on variety of surfaces and inclines
 Kneeling and getting up to standing position
 Stair Climbing
 Functional Exercises : Backward Walking , side-stepping , marching , cone walking
4. To improve Cardiopulmonary Endurance :
 Aerobic Conditioning on stationary cycle , upper body ergometer by increasing duration , example : swimming ,
cycling or walking.
 Bilateral to unilateral stance on stable surface then
progress to unstable surface Upper body Ergometer

Tandem Walking Grapevine walking

Stair Climbing
Marching
 • Full, non-painful ROM (0-115 degrees).
Patient presentation : • Strength of 4+/5 or 85% to 95% of uninvoloved limb.
• Minimal or no pain and swelling.

•Pain Assessment
•MMT
Examination : •Joint ROM
•Functional Analysis

• Allow selected patients to return to advanced level of

function (recreational sports).
Goals: •Maintain and improve strength and endurance of lower
extremity.
• Return to normal lifestyle.
 PHASE IV : INTERVENTIONS
To improve overall strength , endurance , power and balance
to return to full level of functional activities in community :

1. Task specific Strengthening Exercises

2. Proprioceptive Balance Training :
 Balancing on unstable surface while performing
mini squats .
 Partial squatting in unilateral stance , leaning to one
side and picking up an object
 Maintaining balance in unilateral stance while
bending foreward at hips and reaching out with
both arms
 Pertubation in unilateral stance using elastic
resistance on a balance disc
 Jump and freeze progress to hopping up onto a
step and hold the end position .
 Balancing with mini squats Maintaining balance in unilateral stance
while bending foreward at hips and
reaching out with both arms

Partial squatting in unilateral stance,

leaning to one side and picking
up an object

Pertubation in unilateral stance

using elastic resistance on a balance disc
Jump and freeze
progress to hopping up onto a
step
and hold the end position .
 Continued…
3. Advanced Functional Training :

Supine Hamstring Curls on ball

Unilateral Wall slides
Lunges variations :
Multidirectional lunge,
Deep lateral lunge against elastic
resistance.
Sitting down and standing up
from a chair against elastic
resistance
Bilateral or unilateral heel
lowering over a step while holding
additional weights.
 Supine Hamstring Curls

Unilateral Wall slides

Lunges variations

Sitting down and standing up Heel lowering over a step

from a chair against elastic resistance
 PART 09

Exercise Precautions following

TKR
 Exercise precautions following TKR

Monitor the integrity of the surgical incision during knee flexion exercises .
Watch for signs of excessive tension on the wound such as drainage or skin
blanching.

Postpone SLR in side lying position for 2weeks after cemented arthroplasty
and for 4-6 weeks after cement less / hybrid arthroplasty to avoid varus and
valgus stresses to operated knee

If a posterior stabilized prosthesis was implanted avoid hams strengthening in

a sitting position to reduce risk of posterior dislocation of knee.

Avoid placing a pillow or rolled towel under the knee while lying supine or
while seated with operated leg elevated to reduce risk of developing knee
flexion contracture .
 PART 10

Recommendations for participation in Long-term

Activities after Total Joint Replacement
 Recommendations for participation in Long-term
Activities after Total Joint Replacement
Very Good , Good , Need some skills ,
With Care Not Recommended
Highly Recommended Recommended Prior significant Expertise

100% 85% 65% 50% 0%

Baseball
Stationary bicycling Bowling Bicycling (street) Aerobic exercise Basketball
Ballroom dancing Fencing Canoeing Calisthenics Football
Square dancing Rowing Horseback riding Jazz dancing Softball
Golf Speed walking Rock climbing Tennis Doubles Handball
Stationary (NordicTrack) Cross-country skiing Inline skating Jogging
skiing Weight-lifting Nautilus exercises Racq uetba11/
Swimming Ice skating squash
Walking Downhill skiing Lacrosse
Table Tennis Soccer
Tennis-singles
Volleyball
 PART 11

Management of Rehabilitation Problems after Total

Knee Arthroplasty
 Management of Rehabilitation Problems after Total
Knee Arthroplasty
Recalcitrant Flexion Contracture (Difficulty Obtaining
01 Full Knee Extension):
• Initiate backward walking.
• Perform passive extension with the patient lying prone with the knee off the
table, with and without weight placed across the ankle. This should be avoided
if contraindicated by the PCl status of the arthroplasty.
01
• Eccentric extension. The therapist passively extends the leg and then holds the
leg as the patient attempts to lower it slowly.
• With the patient standing, flex and extend the involved knee. Sports cord or rubber
bands can be used for resistance.
• Passive extension is also performed with a towel roll placed under the ankle and the
patient pushing downward on the femur (or with weight on top of the femur) .
Delayed Knee Flexion :
02 • Passive stretching into flexion .
• Wall slides for gravity assistance. 02
• Stationary bicycle.
 PART 12

Bibliography
 BIBLIOGRAPHY
S.Kent Brotzman MD, Kevin E. Wilk PT,
DPT Clinical Orthopaedic Rehabilitation Exercise Therapy by Fiona Wilson , John
– 2nd edition (2nd Edition Mosby ) Gormley , and Juliette hussey

Carolyn KISNER , Lynn Allen COLBY , John Brigham And Women’s Hospital TKR
Borstad – Therapeutic Exercises Protocol by Roya Ghazinouri and Amy
Foundation and Techniques (7thEdition ) Rubin

Essentials of Orthopaedics for An international Journal of Physical

Physiotherapists – John Ebnezar , Therapy
Rakesh John (4th Edition ) Public Library Of Science
THANK YOU