Postoperative Management
Guidelines are similar for management after UKA.
Interventions also may include preoperative patient education on an individual
or group basis. After surgery, patients routinely receive gait training and
exercise instruction while hospitalized and in a subacute rehabilitation facility.
Many patients also receive home-based or outpatient therapy after discharge
from inpatient care. A patient is advanced from one phase of rehabilitation to
the next based on an evaluation of their signs and symptoms and responses to
selected interventions rather than at designated time periods. The type of
fixation used, the patient’s age, size, and bone quality, and whether a knee
immobilizer is worn during ambulation or transfers. With cemented fixation,
weight bearing typically is permitted as tolerated immediately after surgery
using crutches or a walker. During the first few days after surgery, use of a
knee immobilizer may be required. The patient progresses to full weight bearing
over 6 weeks. With biological/cementless fixation, recommendations for
weight bearing vary from permitting only touch-downweight bearing for 4 to 8 weeks
while using crutches or a walker to weight bearing as tolerated within a few
days after surgery while using crutches or a walker. Cane use is indicated as a
patient progresses from partial to full weight bearing. Ambulation without an assistive
device, particularly during outdoor walking, is not advisable until the patient
has attained full or nearly full active knee extension and adequate strength of
the quadriceps and hip musculature to control the operated lower extremity.
Guidelines for exercise after TKA have been reported in the
literature since the mid-1970s. Goals and exercises for progressive phases of
postoperative rehabilitation after current-day TKA.
Many of the exercises described for the early phase of
rehabilitation were reported in a consensus document developed by physical
therapists on the management of patients during the period of hospitalization
after TKA. Prior to discharge from inpatient rehabilitation, a home exercise
program serves as the foundation for the remainder of the rehabilitation
process, with some patients also undergoing home-based or outpatient
rehabilitation for a limited number of visits.
Exercise: Maximum Protection Phase
The focus of management during the first phase of
rehabilitation, which extends for about 4 weeks, is to control pain and
swelling (with cold and compression), achieve independent ambulation and
transfers while using a walker or crutches, prevent early postoperative medical
complications, such as pneumonia and deep vein thrombosis, and minimize the
adverse effects of postoperative immobilization. The goal is to attain 90_ of
knee flexion and full knee extension by the end of this first phase of
rehabilitation. However, full knee extension may not be possible until joint
swelling subsides.The following goals and exercise interventions are included
in the first phase of rehabilitation afterTKA.
Prevent vascular and pulmonary complications
• Ankle pumping exercises with the leg elevated immediately after
surgery to prevent a DVT or pulmonary embolism
• Deep breathing exercises
Prevent reflex inhibition or loss of strength of knee and
hip musculature
• Muscle-setting exercises of the quadriceps (preferably coupled
with neuromuscular electrical stimulation), hamstrings, and hip extensors and
adductors. Assisted progression to active SLRs in supine and prone positions
the first day or two after surgery, postponing SLRs in side-lying positions for
2 weeks after cemented TKA and for 4 to 6 weeks after cementless/ hybrid
replacement to avoid varus or valgus stresses to the operated knee.
• Active assisted ROM (A-AROM) progressing to assisted ROM
(AROM) of the knee while seated and standing for gravity-resisted knee
extension and flexion, respectively.
• As weight bearing on the operated lower extremity permits, wall slides in a standing position, mini-squats, and partial lunges to develop control of the knee extensors and reduce the risk of an extensor lag.
Regain knee ROM
• Heel-slides in a supine position or while seated with the
foot on the floor to increase knee flexion.
• Neuromuscular facilitation and inhibition technique, such
as the agonist-contraction technique
, to decrease muscle guarding, particularly in the
quadriceps, and increase knee flexion.
• Gravity-assisted knee flexion by having the patient sit and
dangle the lower leg over the side of a bed.
• Gravity-assisted knee extension in the supine position by
periodically placing a rolled towel under the ankle and leaving the knee
unsupported or in a seated position with the heel on the floor and pressing
downward just above the knee with both hands.
• Gentle inferior and superior patellar gliding techniques to
prevent restricted mobility.
Exercise: Moderate Protection Phase
The emphasis of the moderate protection phase of rehabilitation, which begins at about 4 weeks and extends to 8 to 12 weeks postoperatively, is to achieve approximately 110_ knee flexion and active knee extension to 0_ and gradually to regain lower extremity strength, muscular endurance, and balance. By 4 to 6 weeks postoperatively if nearly full knee extension has been achieved and the strength of the quadriceps is sufficient, most patients transition to using a cane during ambulation activities. This makes it possible to focus on improving the patient’s gait pattern and the speed and duration of walking. The goals and exercise interventions for this phase of rehabilitation are the following.
Increase strength and muscular endurance of knee and
hip
• Multiple-angle isometrics and low-intensity dynamic resistance
exercises of the quadriceps and hamstrings against a light grade of elastic
resistance or a cuff weight around the ankle. Perform in a variety of positions
to strengthen knee and hip musculature.
Exercise: Minimum Protection and Return to Function
Phases
From the 8th to 12th week and beyond after surgery, the emphasis
of rehabilitation is on task-specific strengthening exercises, proprioceptive
training, and cardiopulmonary conditioning so the patient develops the
strength, balance, and endurance needed to return to a full level of functional
activities. However, patients often are discharged from supervised therapy 2 to
3 months postoperatively after attaining functional ROM of the knee and the
ability to ambulate independently with an assistive device despite persistent
strength deficits and functional limitations. These deficits have been shown to
persist for a year or more after surgery.
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