Updated: 9/5/2020

TKA Postoperative Inpatient Management

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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
 

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