HSS knee arthroplasty

• 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)

• 3
• flex/ext, IR/ER, varus/valgus (ab/adduct)

• 450-500,000 in 2009
• 69 yo
• women>men
• $45-60,000

primary arthritis (aka osteoarthritis) -- obesity, inactivity, genetics

secondary arthritis -- RA, JRA, SLE, Pagets, post-trauma

• OA - natural degen of structures
• RA - autoimmune - body attacks synovial lining of joint

• 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

• 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

pain meds and NSAIDs, wt loss, PT, assistive devices, brace, activity modification

if these fail to improve pain--> candidate for surgery

poor sleep, exhaustion, depression, decreased quantity n quality of sex

absolute: active infection w local or reginional meds, extensor mechanism function, severe vascular disease

• 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

• 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

• edu --> better prepped for post-op life
• exposure to demands of PT
• provide HEP
• gait training
• HSS pre-op class

• ACL it gets replaced w a post
• but many are PCL-sacrificing now too

• trad - it's reflected back
• min invasive - its slid to te side

• 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)

phlebitis (vein inflammation) related to a thrombus (blood clot)

• 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

• 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

• 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

• 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)

• 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

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

• 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

• 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

• 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)

ROM

• 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)

65-75 degrees

80-85 degrees

90-100 degrees

• 95-105
• 105

190 degrees

• 115 degrees - that's enoguh for walking, stairs, sit<--->stand, tie a shoe
• 140 degrees

• 1: 1-5 days post-op
• 2: 1-8 weeks post-op
• 3: >8 weeks

• 1: 85 - 90 degrees
• 2: 90 - 105-110 
• 3: > 110

• pre-op: degree of contraction
• intra-op: surgical precision
• post-op: pain management, arthrofibrosis

• 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)

• wound dehiscence
• patellar tendon avulsion
• supracondylar fractures
• hemarthrosis - swelling in joint
• heterotropic bone formation - turns to hard bone

• 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

• 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

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

• up, 2x body wt
• down, 3x body wt

• 20%
• <50%
• ~90%
• no clear study saying strengthening quad beforehand helps post-op

• 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

• do more fun physical activities (balancing, more complex movemnts
• be comfy w ADLs,
• continue treatment but increase
• prep for discharge

• (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

• low impact aerobics
• walking
• tationary bike
• olf
• bowling
• shurfflebor
• croquet
• horseshoes
• swimming
• horse riding
• balloom/jazz/square dance
• ... low impact exercise

anything w much impat, like gymnastics, jogging, basketball, etc

• osteolysis
• implant loosening or failing
• natural wear
• infections

• 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)