Postoperative knee managment

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.

Exercise

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.

Physio Guideline

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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