TOTAL KNEE

ARTHROPLASTY

FAIZA AMJAD
LEC-7
INTRODUCTION
• TKR is divided into three categories
1. the linked prosthesis,
2. the resurfacing implant,
3. the conforming implant.
• linked prosthesis
• In the linked prosthesis, the femoral and tibial
components are physically fastened together at the
time of manufacture or at some point during the
surgical procedure.
• The linked prosthesis may be fully constrained, there
by permitting only flexion and extension, or it may
permit flexion, extension and limited axial rotation.
• The linked prosthesis is no longer commonly used
because of the loosening of components that occurs
when stresses are applied to the tibial side of the
joint.
• However, they may be appropriate for patients who
have markedly unstable knees or after failure of one
or more previous arthroplasties.
• Resurfacing implant
• A resurfacing implant has a flat poly
ethylene tibial surface that articulates with
the metallic femoral condylar component.
• A resurfacing implant requires proper
balancing of the collateral and cruciate
ligaments and, therefore, is not indicated in
a case in which either the cruciate or the
collateral ligament is absent or deficient.
• Because a large number of patients with
advanced arthritis have a missing or
attenuated cruciate ligament and
compromised soft-tissue balancing, which
is necessary for the procedure to succeed,
resurfacing implants are not the primary
choice of many surgeons.
• Conforming implant
• A conforming implant consists of a metallic femoral
condylar component and a polyethylene tibial
component.
• Designed to resist some of the translator and shear
stresses, they are currently used in 95% of all TKR
procedures.
• The design of the conforming implant requires
surgical sacrifice of the anterior cruciate ligament
and,in some cases,depending upon the design of
the particular implant, also the posterior cruciate
ligament.
• The posterior cruciate is almost always removed in
cases in which the patient presents with a fixed
varus or valgus contracture of 15-20"and the
associated fixed flexion deformity
 FIXATION OF THE IMPLANT
• Surgical fixation of all of the knee components is accomplished through one of two methods.
• The first involves the use of polymethylmethacrylate bone cement; one or both of the components
is cemented to the bone surface. In the second method, the implants are inserted and one or both
of the components are attached in a cement less manner.
• Although cemented knee components are still utilized, the preferred mechanism for attachment is
cementless.
• Some of the problems that have been identified with the use of cemented components include the
following:
1. The polymethylmethacrylate bone cement is known to be brittle. If the cement fragments in the
joint, it can become trapped between components, which results in excessive component wear.
2. As the polymethylmethacrylate hardens, it is known to become thermo toxic to adjacent bony
cells. It has also been known to decrease leuko-taxis (attraction of leukocytes) and thereby increase
the risk of infection at the implant site.
3. The use of bone cement is known to make surgical revision more difficult.
• The cementless technique relies upon bone growth on to porous or
roughened surfaces for firm fixation.
• Proper and precise surgical placement of cementless components is
essential if firm component attachment is to be obtained. Studies
indicate that bone will not grow across gaps greater than 1-2 mm.
• The choice of component may be based upon the patient's level of
strenuous physical activity, age, health and well-being, and bone
density.
• The primary contraindication to the use of a cementless component is
severe osteoporosis.
• Monitoring for potential infection is particularly important in TKA because a
large amount of foreign material is implanted in a superficial joint.
• Although a TKA is a relatively safe orthopedic procedure, wound-healing
difficulties can occasionally be seen, including problems such as marginal
wound necrosis, skins sloughing, sinus tract formation and hematoma
formation.
• The presence of any of these complications may adversely affect the outcome.
• This is especially true with regard to range of motion(ROM), in cases in which
therapy must be stopped until the problem can be resolved.
• The use of the minimally invasive total knee replacement may, however,
reduce the potential for postoperative complications
REHABILITATION
• In patient postoperative rehabilitation considerations
• A patient with an uncomplicated TKA is generally encouraged to walk on the
first day postoperatively, even if ambulation time is brief.
• The role of the therapist is to encourage mobility, self-care, proper weight-
bearing and gait, and getting into and out of bed in the proper manner.
• During the first few days after surgery, use CPM.
• These devices are used two or three times a day in conjunction with physical
therapy exercises and ROM and gait training sessions.
• Prepare the patient for home rehabilitation program.
• Train in how to negotiate steps and flights of stairs, carpeted surfaces and
surfaces that might been countered outside the home.
• Proper positioning of the knee during sleep in order to prevent unwanted
contractures.
• The performance of the activities of daily living should be discussed with
the patient and the immediate caregivers.
• TKA procedures are performed in members of the geriatric population,
special attention should be paid to any impairments of vision, balance or
endurance that may have occurred.
• A falls risk assessment should be performed and documented.
• Patients should be encouraged to monitor the integrity of the wound site
on a daily basis and to use safe ambulation procedures until outpatient gait-
training needs can be addressed.
• Out patient and home-health care rehabilitation considerations
• In the initial stages(0-4weeks),it is vital to maximize ROM.
• Functional ROM is considered to be between110 and120"of flexion and full
extension.
• Patients should be actively involved in home programs that focus upon the
prevention of flexion or extension contractures of the knee.
• In the period between0 and 4 weeks after surgery, rehabilitation should focus upon
strength gains in the quadriceps, hamstring, hip flexor and hip extensor muscles.
• The patient may be allowed to progress to walking with full weight-bearing, as
indicated by the physician.
• A patient who has undergone the cementless technique may be required to
maintain limited weight-bearing for a period of 4-6 weeks or until sufficient new
bone growth can be seen by the physician using radiography.
Desired rehabilitation outcomes for the
TKA patient
• Patients who undergo TKA commonly require extensive outpatient physical
therapy for a period of approximately 6 weeks in order to maximize ROM.
• Swelling may persist for several months until sufficient collateral circulation
can develop.
• Persistent or excessive calf pain and swelling should not be ignored because
asymptomatic deep vein thrombosis may occur in up to 40% of TKA
patients, even up to 18 months after surgery
• The use of home ROM programs as well as general conditioning exercises
allows the patient to resume normal activities quickly.
• Strenuous exercise is to be avoided until approved of by the physician.
• The patient may progress from using a walker to using a cane and then to
ambulating with no assistive devices, as tolerated by the individual.
• Differences in leg length should be assessed and a shoe insert may be
recommended if gait abnormalities persist.
• After several months, patients are often encouraged to resume physical
activities in moderation, for example golf, tennis, bicycle riding and
walking.
• Although TKA is very effective in relieving pain, it is important to note that
functional activities of daily living, for example stair climbing, getting in
and out of a bath, negotiating ramps and sitting in low chairs, may be
compromised.
• It is worth bearing in mind that, in general, patients with better preoperative knee
flexion have a better postoperative ROM, even though they lose more motion than
patients who have a worse ROM going into surgery.
• In other words, those with considerably less ROM going into surgery tend to gain rather
than lose ROM.
• Obesity, prior surgery and tightness of retained posterior cruciate ligaments are
additional factors that may compromise knee flexion.
• The minimal amount of knee flexion necessary for most normal activities.
• If sufficient flexion is not attained, a manipulation under anesthesia may be performed .
• Underlying causes of persistent knee pain and limited flexion include arthrofibrosis,
infrapatellar spur, impinging hypertrophic synovitis, impinging posterior cruciate
ligament and prosthetic wear or loosening.
• These diagnoses were made after arthroscopies of problematic knees with
improvements noted postoperatively.
THE AGING BONY THORAX
KINESIOLOGY
• Mechanics of the ribs
• Muscles of the thorax
• Postural stresses on the thoracic spine
PATHOLOGIES INVOLVING THE BONY
THORAX
• Obstructive lung diseases
Obstructive lung diseases cause an over inflated state in the lungs.
The thoracic cage tends to assume the inspiratory position
the diaphragm becomes low and flat.
The anteroposterior (AP) and transverse diameters of the chest are
increased
the ribs and sternum are always in a state of partial or complete
expansion.
 Restrictive lung diseases
In restrictive lung diseases, the lungs are prevented from fully expanding
It is because of restrictions in the lung tissue, pleurae, muscles, ribs or sternum.
The AP and transverse diameters of the chest should increase with inspiration but
do not increase to normal levels in these conditions.
• Causes
o Interstitial fibrosis, sarcoidosis and pneumoconiosis are examples of disease
processes that decrease elasticity (or compliance) of the lung tissue.
o pleural tissue abnormalities, such as pleurisy, pleuritis and pleural effusion, cause
compression of the lungs. Also, any condition that elevates the diaphragm and
prevents full excursion of this muscle diminishes the ability of the chest to expand.
Examples of such conditions are ascites, obesity and abdominal tumors of any kind.
o Numerous musculoskeletal conditions cause disturbed respiratory mechanics.
o The autoimmune(collagen)diseases can affect any joint in the body, including the
costochondral and costovertebral joints
o Additionally, these are systemic diseases and, therefore, they can also involve the
pleural or lung tissue as well. Rheumatoid arthritis, systemic lupus erythematosus
and scleroderma are examples.
o Other less severe forms of autoimmune disease such as fibromyalgia and
dermatomyositis may affect the musculature and can cause pain and restriction
of the myofascial structures and thereby limit chest expansion.
Costochondritis(TIetze's syndrome)is an inflammatory condition of the
costochondral tissue that can be viral or occur secondary to strain or unknown
reasons. The symptom of chest pain can occur with this condition and be
mistaken for myocardial infarction. An effusion of the costosternal joint may be
mistaken for a painful breast lump during self-breast examination.
Other condition that can cause problem in
bony thorax
• Orthopedic conditions such as kyphosis, scoliosis and kyphoscoliosis
primarily affect the vertebral segments and costovertebral articulations.
• Even with mild changes of spine alignment, the mechanics of the ribs and
sternum are altered. In severe cases, the lung tissue, heart and major
vessels may be compromised by the deformity and altered mechanics.
• Ankylosing spondylitis can be considered in the autoimmune and
orthopedic categories. It is considered separately here because of the
severe consequences it can have on the thorax. In this condition, there is
gradual fusion of spinal zygapophyseal joints, usually starting in the
sacroiliac joints. As more and more of the spine becomes involved, X-rays
demonstrate a bamboo-like image (bamboo spine).
• There is calcification of the spinal segments as well as of the costovertebral joint,
which causes Severe restriction of chest expansion (Dutton2004).
• Accidental or surgical trauma can cause muscle splinting, which may restrict chest
expansion or relaxation.
• After thoracic and cardiovascular surgery there is a tendency for the patient to
breathe in a shallow, rapid and guarded manner, using accessory muscles such as
the scalenes and sternocleidomastoids rather than the diaphragm. Even after
healing, the posture of such patients has often changed and shows an increase in
thoracic kyphosis, a marked forward-thrust head, protraction of the shoulder
girdles and an adducted and internally rotated position of the shoulders. The
acquired posture compromises not only spinal and respiratory function but also
function of the upper extremities
• Another type of trauma to the thorax that is not often considered is an injury
that occurs during a motor vehicle accident. If the person is using a seat
belt/shoulder strap type of restraint at the time of the accident, the shoulder
strap may cause damage to the thoracic fascial structures and muscles or
sternum and ribs, as well as fractures. However, soft-tissue and joint injuries
are often over looked, even though they may contribute to painful postural
and respiratory dysfunction.
• Compression fractures in the thoracic spine are common place in the geriatric
population. The increased mechanical stresses that result from the forward-
thrust head, rounded shoulder, kyphotic posture that frequently follows a
thoracic compression fracture, predispose the individual to further pain,
reduced spinal motion and compromised function
• Also, multiple compression fractures may lead to a protruding abdomen with
reduced abdominal cavity space and subsequent difficulty with eating a normal
meal.
• The floating ribs may rest upon the iliac crests leading to considerable pain
• When muscular, fascial, spinal, rib or sternal components are the cause of
restriction of lung capacity, the patient may benefit from physical therapy, which
can improve mechanics and lower the pain factor, thus improving quality of life
inspite of the underlying disease process