HSS knee arthroplasty

  1. arthroplasty def and two ypes for the kne
    • a surgical procedure where componnents of a diseased joint are resected and replaced with artificial componts
    • TKA - total knee arthroplasty
    • UKA - uni-condylar knee arthroplasty (just in someo fo femur and tibia)
  2. degreees of freedom in knee
    • 3
    • flex/ext, IR/ER, varus/valgus (ab/adduct)
  3. TKA stats - # performed in 2009, av age of pt, gender, cost
    • 450-500,000 in 2009
    • 69 yo
    • women>men
    • $45-60,000
  4. primary or secondary arthritis usually lead to TKA -- some contributing factors to each?
    primary arthritis (aka osteoarthritis) -- obesity, inactivity, genetics

    secondary arthritis -- RA, JRA, SLE, Pagets, post-trauma
  5. diff btwn OA and RA
    • OA - natural degen of structures
    • RA - autoimmune - body attacks synovial lining of joint
  6. indications for a TKA
    • pain that is chronic and >5/10 even with meds
    • stiffness, loss of ROM, postural deformities ex. flexion contracture, genu varum or valgus that's exacerbated by arthritis
    • chronic swelling
    • antalgic gait (may need a cane or walker)
    • supportive diagnostic x-rays
  7. real basics of what you see on knee x-rays
    • there can be a black space between bones -this is cartilage... yay.
    • that black space can be really thin, so it's essentially bone on bone... ow.

    can be consistant across a joint, or could just be at one side
  8. conservative management of knee pain, techniques
    pain meds and NSAIDs, wt loss, PT, assistive devices, brace, activity modification

    if these fail to improve pain--> candidate for surgery
  9. social and emotional side effects of knee pain
    poor sleep, exhaustion, depression, decreased quantity n quality of sex
  10. absolute contra-indications for TKA
    absolute: active infection w local or reginional meds, extensor mechanism function, severe vascular disease
  11. relative contraindications for TKA
    • medical conditions, (pt needs meuromuscular control to get the TKA, and a good vascular system to avoid infection) 
    • h/o osteomyelitis (bone deteriation over time),
    • neuropathic joint/"Charcot" (w neuropathy pt won't be able to know what's going on in knee... risk factor since pt won't know if things are going badly)
    • progressive neurologic disease (ex. ALS - see if pt can use body to help self recover)
    • morbid obesity
  12. does pre-op PT help a TKA? (according to studies)
    • 2 studies say it doesn't help w ROM or functional scores, but leasds to shorter hospital stays and less rehab time
    • 1 says it appears efficacious in influencing functional activities

    thing is, as soon as you incise you shut down the quad --> atrophy
  13. advantages of pre-op PT for a TKA
    • edu --> better prepped for post-op life
    • exposure to demands of PT
    • provide HEP
    • gait training
    • HSS pre-op class
  14. what lig are you likely to not have after a TKA
    • ACL it gets replaced w a post
    • but many are PCL-sacrificing now too
  15. patella movement in a trad and  a min invasive surgery
    • trad - it's reflected back
    • min invasive - its slid to te side
  16. acute complications from TKA
    • peri-prosthetic fractures/ligamentous injury
    • blood clots (DVT) - thrombophlebitis
    • infection
    • nerve injury (peroneal n.)
    • change in mentation - personality shift due to anesthesia (more likely in the elderly)
  17. thrombophlebitis
    phlebitis (vein inflammation) related to a thrombus (blood clot)
  18. 5 things to think about post-op
    • 1) get pt medically stable
    • 2) give pt DVT prophylaxis - ex. cumadin to thin blood to limit clots
    • 3) analgesia - such as a PCA (personally controlled analgesic - pt clicks a button to get a dose)
    • 4) cryotherapy - this addresses the swelling
    • 5) rehab - but keep in mind phases of muscle and bone healing
  19. goals for acute post-op rehab (days 1-5)
    • unassisted transfers
    • unassisted amb. w appropriate device on level surfaces and stairs
    • ability to indep. perform HEP
    • A/AAROM flexion > 80 (sitting) extension < 10 (supine)
    • assist in mental and emotional support - help pt have reasonable expectations
  20. precautons for acute post op (days 1-5)
    • avoid prolonged sitting, standing, walking
    • severe pain w walking and ROM exercises
    • find the right balance of rest:activity for the specific pt
    • pay attention to how pt is responding to meds
  21. studies show no funtional benefit to CPM (cont. passive motion) machines, but HSS uses them anyway. List advantages and disadvantages to it
    • advantages:
    • promotes early knee flexion
    • helps decrease pain
    • desensitizes pt to movement (psych benefit)

    • disadvantages:
    • may increase blood loss thru incision
    • may increase wound complications
    • undermine extension
    • can promote dependence
    • can increase pain (yes, goes both ways)
  22. treatment strategies for day 1-5
    • CPM, starting at 60 degrees, increasing as tolerated
    • transfer training, gaittraingin WBAT w appropriate assistive device
    • ADL training
    • cryotherapy
    • elev to prevent edema
    • HEP to strengthen quads, gluts, hammies isometrically. SLR, AROM knee extension. Sitting hip flexion. ROM exercises. A/AAROM knee flex in sitting. Passie knee ext w towel under ankle. Stair stretch
  23. HEP in acute rehab should include...?
    strengthen quads, gluts, hammies isometrically. SLR, AROM knee extension. Sitting hip flexion. ROM exercises. A/AAROM knee flex in sitting. Passie knee ext w towel under ankle. Stair stretch
  24. more exercises for stage 1
    • ankle pumps
    • quad sets - supine, push knee down
    • glut sets - squeeze tush
    • heels slides on table to promote ext/flex at knee
    • lunge stretch on a stair
    • ext stretch on a stair 15-30 sec, 10-20 reps, 2-3x/day
    • crossed legs hanging off a table, use strong one to push weak into flex/ext
  25. goals for the the end of stage 1
    • able to transfer in/out bed w little to no assistance
    • amb > 200ft w cane or rolling walker
    • non-reciprocal stair negotiaion w hand rail and cane
    • indep dressing using ADL equip
    • regular use of cryotherapy
    • no CPM
    • 2-3x daily perform therex, ROM, stretching
    • AROM/PROM KE 0-5
    • AROM/PROM KF 85-90
  26. diffs in treatment btwn in-pt acute rehab and home PT
    • in-pt: 2-3hrs/day of therapy 1-2 weeks, then home
    • home PT: 1hr 2-3x week, 1-6 weeks

    (takeaway - inpatient acute/subacute care rocks)
  27. sub acute rehab, phase 2, 2-8weeks, main goal?
  28. treatment stragegies in phase 2 (sub acute, weeks 2-8)
    • passive extension w toel extensions, prone hang
    • active knee flex/et exercise
    • AAROM knee flexion - manual, heel slides on table and wall
    • short crank bike
    • edema control w cryotherapy, elevation, modulations
    • patellar mobilization
    • estim or biofeedback for quads re-edu
    • SLR in all plnes
    • forward step-up progression, raising height of steps
    • balance/proprioceptive trainig
    • Tug and other tests
    • gait training w assistive evice - emphasize active knee flexion, extension, heel-strike, reciporcl pattern, symmetrical wt bearing
    • ADL training (tub, car, in/out)
  29. knee flexion needed for swing phase of gait
    65-75 degrees
  30. knee flexion to ascend stairs
    80-85 degrees
  31. knee flexion needed for descending stairs
    90-100 degrees
  32. knee flexion for sit ad risefor standard low chair
    to tie a shoe
    • 95-105
    • 105
  33. suggested COMBINED hip and knee flexion ROM
    190 degrees
  34. av flex reached by TKA pts by 1 yr
    flexion needed for a squat
    • 115 degrees - that's enoguh for walking, stairs, sit<--->stand, tie a shoe
    • 140 degrees
  35. phases 1-3 by timing
    • 1: 1-5 days post-op
    • 2: 1-8 weeks post-op
    • 3: >8 weeks
  36. kne flexion goals for stages 1-3
    • 1: 85 - 90 degrees
    • 2: 90 - 105-110 
    • 3: > 110
  37. factors that affect post-op ROM -- from the pre, intra, and post op times
    • pre-op: degree of contraction
    • intra-op: surgical precision
    • post-op: pain management, arthrofibrosis
  38. manipulation under anaesthesia (MUA)
    • application of steady pressure to tibia until firm endpoint is reached (yr breaking up scar tissue)
    • it's performed 8-10 peeks post-op if ROM has plateaued (under general anesthesia)
  39. complication from MUA
    • wound dehiscence
    • patellar tendon avulsion
    • supracondylar fractures
    • hemarthrosis - swelling in joint
    • heterotropic bone formation - turns to hard bone
  40. perils of having limited knee extension, maybe going only to 10degrees, not to 0
    • hip flexor shortened
    • back extensors stretched
    • glut extended - weak
    • hammies can't extend - weak
    • soleus is shortened - weak
    • tib ant is lengthened - weak
    • ant translation of femur on tib - aggravation
    • pressureon patellar tendon
  41. chain of events triggered by poor knee extension
    • knee flexion contracture -->
    • antalgic gait -->
    • anterior knee pain and quad inhibition -->
    • hip flex contracutre and weakness w hammy weakness-->
    • ankel weakness in gastroc and soleus and ant tib -->
    • poor proficiencey w movement, increased energy expenditure -->
    • poor activity tolerance & disability
  42. phase 2 exercises
    quad sets, mini leg raises, strengthen hips's ER and IR, bridges for glut an core strength, leg presses, knee ext w theraband, flexion w weights, single leg standing or wt shifting, step up nd over objects, sit <--> stand, balance on unsteady surfaces, etc. both close and open chain
  43. strength of body wt needed to go up and down stairs
    • up, 2x body wt
    • down, 3x body wt
  44. quads weakness - how much is brought on by OA? how much can be regained 1 month post-op? how much 6-12 months later?
    • 20%
    • <50%
    • ~90%
    • no clear study saying strengthening quad beforehand helps post-op
  45. goal for the end of phase 2
    • indep w transfers
    • amb w cane indoors and out
    • amb > 4 blocks at a time
    • trial reciprocate stairs going up, non recip down
    • indep w ADLs
    • cryotherapy
    • progressing w HEP
    • KE to 0 degrees
    • KF 100-110
  46. in rehab in phase three...?
    • do more fun physical activities (balancing, more complex movemnts
    • be comfy w ADLs,
    • continue treatment but increase
    • prep for discharge
  47. when to discharge pt
    • (insurance may dictate, but in case not...)
    • dependent on prior level of function
    • indep w dressing using ADL equipment
    • indep w HEP
    • amb. w/o antalgia w least restrictive device
    • non reciprocal stairs w hand rail or cane
  48. recommeded activities after TKA
    • low impact aerobics
    • walking
    • tationary bike
    • olf
    • bowling
    • shurfflebor
    • croquet
    • horseshoes
    • swimming
    • horse riding
    • balloom/jazz/square dance
    • ... low impact exercise
  49. not-recommended exercise after TKA
    anything w much impat, like gymnastics, jogging, basketball, etc
  50. some reasons for tka failure
    • osteolysis
    • implant loosening or failing
    • natural wear
    • infections
  51. what to do if you nee a TKA revision due to infection
    • first, antibiotics
    • then, hospital admissio for implant removal, then a cement spacer w antiobiotics implanted is put in and monitored for 6 weeks, then the spacer is removed and a new TKA is performed
    • last resort = arthrodesis (fusion)
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HSS knee arthroplasty
HSS knee arthroplasty