Introduction Rehabilitation requires coordinated effort from orthopaedic surgeon physical therapist occupational therapist case manager nursing staff patient and patient's family Care can be broken down into different phases including inpatient acute care (hospital) inpatient extended care (rehab/SNF) outpatient home care Patient Management Pain management preoperative NSAIDS and opioids given immediately before procedure reduce postoperative pain intraoperative regional anesthesia (spinal and/or epidural) preferred over general anesthesia peripheral nerve blocks useful adjuvant to decrease postoperative pain periarticular multimodal drug injection decrease postoperative pain with minimal risks postoperative multimodal oral drug therapy gold standard and includes NSAIDs: Inhibit COX-1 and COX-2 ? inhibition of inflammatory mediators ( PGs, TXA, AA) opioids Mu agonist leading to neuron hyperpolarization and reduced excitability NSAIDs inhibit COX-1 and COX-2 inhibition of inflammatory mediators (PGs, TXA, AA) selective COX-2 inhibitors inhibits transformation of AA to PG precursors minimizes GI effects may inhibit bone healing gabapentin/pregabalin reduce hyper-excitability of voltage dependent Ca2+ channels in activated neurons. pregabalin= better oral bioavailability. SNRIs inhibition of serotonin and noradrenergic reuptake in the CNS *Selective COX-2 inhibitors ? inhibits transformation of AA to PG precursors; minimizes GI effects May inhibit bone healing Gabapentin/Pregabalin: Reduce hyper-excitability of voltage dependent Ca2+ channels in activated neurons. Pregabalin= better oral bioavailability. SNRIs: Inhibition of serotonin and noradrenergic reuptake in the CNS Opioids: Mu agonist leading to neuron hyperpolarization and reduced excitability Physical therapy therapy should start on the day of surgery reduces length of hospital stay reduced pain and improves function Range of motion requirements swing phase of gait 65° of flexion activities of daily living 90° of flexion stairs 95° of flexion rise from a chair 105° of flexion Continuous passive motion (CPM) machine improve early knee flexion has not been shown to have a long-term benefit Drain Placement has not demonstrated any difference in complications or outcomes Discharge home criteria medically stable 80-90° AROM knee flexion ambulate 75-100 feet ascend or descend stairs Post-Operative Anemia Intra-operative Earlier discharge to rehab from hospital associated with improved outcomes Discharge criteria to home similar to those in hospital Rehabilitation Physical therapy 2-3 times per week for at least 2 weeks focused on closed-chain concentric exercises gradually advance from crutches to cane to unassisted other modalities include but not limited to aquatic therapy buoyancy attenuates gravity/compressive forces in joint; provides resistance balance training proprioception and postural control cryotherapy correlation between local temp and synovial PGE2 neuromuscular electrical stimulation (NMES) may override deficits in muscle activation caused by CNS impairments Return to activities low-impact closed chain exercises preferred eliptical biking golf handicap will show rise after TKA (stays same with THA) impact activities may decrease longevity of implant running is discouraged Driving recommendations 4 weeks after a right total knee < 4 weeks after a left total knee
All Videos (1) Podcasts (0) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Evolving Technique Update: Acetaminophen Injection For Postoperative Pain Can Make A Difference In Your Patient Satisfaction - Michael P. Ast, MD (OSET 2018) Michael P. Ast Recon - TKA Postoperative Inpatient Management 7/25/2019 154 views