Updated: 2/26/2017

TKA Rehabilitation

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Evidence
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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
Inpatient Acute Care (Hospital)
  • 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

  • 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  
  • Discharge home criteria
    • medically stable
    • 80-90° AROM knee flexion
    • ambulate 75-100 feet
    • ascend or descend stairs
Inpatient Extended Care (Rehab)
  • Earlier discharge to rehab from hospital associated with improved outcomes
  • Discharge criteria to home similar to those in hospital
Outpatient Care
  • 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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Technique Guides (3)
Questions (4)

(OBQ11.16) A 68-year-old right handed male golfer presents with significant left knee pain which has not been amenable to conservative management. A radiograph is shown in Figure A. He is interested in pursuing total knee arthroplasty (TKA). What can this patient expect with regards to his golf game after undergoing this procedure? Review Topic

QID: 3439
FIGURES:
1

A significant rise in his handicap

48%

(1505/3122)

2

No change in his drive distance

34%

(1060/3122)

3

Decreased pain compared to undergoing a right TKA

11%

(359/3122)

4

A significant chance of having severe pain during play

3%

(88/3122)

5

Patients are required to use a cart while golfing

3%

(96/3122)

ML 4

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PREFERRED RESPONSE 1
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(OBQ10.109) Which of the following statements regarding the use of continuous passive motion (CPM) devices following total knee arthroplasty is true? Review Topic

QID: 3203
1

The use of CPM decreases the incidence of knee flexion contracture at 6 months following surgery.

2%

(54/2280)

2

The use of CPM has been associated with a decreased incidence of secondary surgery for knee manipulation.

2%

(37/2280)

3

The use of CPM has not demonstrated any difference in clinical outcomes at one year following surgery.

93%

(2119/2280)

4

The use of CPM has been associated with increasing analgesic pain requirements in the first 3 days following surgery.

2%

(55/2280)

5

The use of CPM decreases knee flexion at one year following surgery.

0%

(4/2280)

ML 1

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PREFERRED RESPONSE 3
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Topic COMMENTS (1)
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