Total Knee Replacement Season – What does the rehab look like?


Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less.  An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.

The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA).  So what does the rehabilitation process involve?

The first thing to understand is that 50% of a successful outcome is the caliber of the surgery.  If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly.  That is the easy part of the process; after all you slept through it!

Then you wake up and realize your knee hurts.  It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work.  You have difficulty transferring from supine (lying on your back) to sitting and then to standing.  Now you have to walk with a walker, another foreign experience.   After 3-5 days, the doctor may send you home from the hospital.  Now you need to get into the car to be driven home.  This requires you to bend your new knee, another daunting thought.  Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.

HELP!

Physical therapists now become your best friends and should be for a number of weeks to months following the surgery.  You will be guided through a steady progression to return you to full function.

FIRST INPATIENT PHYSICAL THERAPY:

You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker.  You will also need to ascend and descend stairs,  You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair.  Detailed instruction should be given regarding how to control the postoperative swelling.

Avoiding DVTs:  perform the embolic isometric contraction sequence of the calf, quadriceps and gluteus musculature (in that order).  Also, do ankle pumps.

Surgical wound care:  keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently.  The knee became infected and was never the same again.  Luckily it was not a TKA and the infection, therefore, did not enter the bone.  It is worthwhile doing it right and accepting you will be a little dirtier than usual!

Walking:  The majority of TKA patients start walking with a front wheel walker, day one or two after surgery.  The large base of support gives the individual more stability.  You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently.  This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon).  As a result, you have difficulty straightening your knee and controlling it in full extension.  When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.

Negotiating stairs with your walker:  The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker.  All homes have at least one to three steps to ascend from the garage to the house or at the front door.  Just remember:  the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.

AROM:  Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!).  The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight.  They will also instruct you in heel slides to regain knee flexion.  If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game.  With 90° of flexion you can get into and out of as well as sit in the car that will take you home.

Transfers:  Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent.  You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode,  avoiding low chairs like a couch.  You walker is your friend here to and you must focus on safety in all your mobility.

Control the swelling:  This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail).  Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day.  You, the patient, must be vocal about this to get it done.  You will be glad you followed this procedure.  Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them.  Do not get the bandages wet (see paragraph above on infection!).  Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.

Now you are home.  Feel better already, albeit a little beaten up I am sure.  Out patient physical therapy now takes over.  (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).

OUT PATIENT PHYSICAL THERAPY:

The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists.  Here is where the hard work really starts and you must be dedicated.  Focus on the right things and you will get a great result.

Note: There is no need for the physical therapist to aggressively bend or straighten your knee.  This may inflame the joint and increase the likelihood of arthrofibrosis.  I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required.  I measure at the beginning of each physical therapy session to track progress.  If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.

Rehabilitation is typically broken down into phases.  Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling.  Progression is not based purely on a timeline.

Phase 1:  Post op days 1-10

Goals:

  1. Understand the goals of the rehabilitation process.
  2. Good pain control (pain less than 5/10)
  3. Good control of swelling.
  4. Can contract your quadriceps.
  5. Can do a straight leg raise (SLR) with minimal lag (minimal loss of full knee extension when you raise your leg off the table while sitting).
  6. Full passive extension (straight knee).
  7. Active knee flexion 90°.
  8. Independent gait and transfers.

Phase 2: Weeks 2 – 12 post-op

Goals:

  1. AROM 0°-130° (we routinely are attaining 140° or more)
  2. Mild joint effusion (swelling within the joint).
  3. Can keep knee straight between physical therapy sessions.
  4. Full SLR.
  5. Normal gait pattern.
  6. Independent in a suitable gym and/or home program based on specific individual needs of the patient at discharge.

So, there is a lot of work to do in recovering from a total knee replacement.  It is not rocket science but it does require focused dedication.  Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.

Your call to action:

  1. If you are planning on a total knee replacement (or any other joint replacement) and have questions of any sort, call us at Custom Physical Therapy and a physical therapist will address your questions.  Call 775-331-1199.
  2. Forward this to a friend, family member or coworker who may be having a total knee replacement.
  3. Forward this post to your physician and have them post a comment.  It would be great to have their input too.
  4. If you have had a total knee arthroplasty, please post a comment.  People having knee replacements would benefit from hearing what worked and what challenges you faced during your recovery.
  5. Do something kind for a stranger today!

 Thanks for reading this.

 André

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