POST-OpERATIVE GUIDELINES FOR pATIENTS HAVING KNEE REpLACEMENT SURGERY

PATIENT INFORMATION BOOKLET

THE GALWAY CLINIC DEpARTMENT OF PHYSIOTHERApY

Reproduced from the Arthritis Research Campaign information booklet www.arc.org.uk

Make your next appointment online @ www.galwayclinic.com

TABLE OF CONTENTS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Structure of the Knee Suitability for TKR Information on TKR Physiotherapy Exercise Programme for TKR Modalities Your Goals Protocol Post Operation When Can I Leave Hospital What Happens When I go Home Other Considerations Stairs Technique Glossary Notes

Page No. 2 3 4-6 6 7-9 10 11 12-17 18 18-19 20-21 22 23 24-25

THE HEALTHY KNEE

The knee is a complex hinge joint. The surfaces of the thigh and shin bone are smooth and lubricated with joint fluid so they can roll, rotate and glide over each other easily. Cartilage covers the bones evenly, allowing smooth movement.

Adapted from KRAMES Communications

Meniscii are half moon shaped pads that lie at the bone ends and help shock absorption. Ligaments bind the bones together and support/stabilize the knee Muscles move the joint and help reduce the stress on it e.g. quadriceps and hamstrings Articular Cartilage is the grizzly material coating the ends of the bones. This wears away in OA.

WHO IS A CANDIDATE FOR A TOTAL KNEE REpLACEMENT?

Total knee replacements are usually performed on people suffering from severe arthritic conditions. Most patients who have artificial knees are over age 55, but the procedure is performed in younger people. The circumstances vary somewhat, but generally you would be considered for a total knee replacement if: You have daily pain. Your pain is severe enough to restrict not only work and recreation but also the ordinary activities of daily living. You have significant stiffness of your knee. You have significant instability (constant giving way) of your knee. You have significant deformity (lock-knees or bow-legs).

TOTAL KNEE REpLACEMENT

This is a surgical procedure in which the injured or damaged parts are replaced with artificial parts. The procedure is performed by separating the muscles and ligaments around the knee to expose the knee capsule (the tough, gristle like tissue surrounding the knee joint). The capsule is opened, exposing the inside of the joint. The ends of the thigh bone (femur) and the shin bone (tibia) are removed and sometimes the underside of the kneecap (patella) is removed. The artificial parts are cemented into place. The new knee consists of a metal shell on the end of the femur, a metal and plastic cover on the tibia.

WHAT CAN I EXpECT FROM AN ARTIFICIAL KNEE?

If replacement provides you with pain relief and if you do not have other health problems, you should be able to carry out many normal activities of daily living. The artificial knee may allow you to return to active sports or heavy labour under your physicians instructions. Activities that overload the artificial knee must be avoided. About 90 percent of patients with stiff knees before surgery will have better motion after a total knee replacement.

WHAT ARE THE RISKS OF TOTAL KNEE REpLACEMENT?

Total knee replacement is a major operation. The majority of patients have no complications but they can occur. Risks vary according to your general health and you should discuss the risks and benefits with your surgeon.

PHYSIOTHERApY
When muscles are not used, they become weak and do not perform well in supporting and moving the body. Your leg muscles are probably weak because you have not used them much due to your knee problems. The surgery can correct the knee problem, but the muscles will remain weak and will only be strengthened through regular exercise. You will be assisted and advised how to do this, but the responsibility for exercising is yours. Dont forget to pack the appropriate clothing for your exercise therapy. E.g. comfortable loose clothes and non-slip footwear (e.g. trainers, rubber heeled shoes). Slip-on shoes with no heel support are NOT APPROPRIATE for gait retraining!! Physiotherapy sessions will take place in the Galway Clinic Physiotherapy Department daily. Your physiotherapist will tell you when you are ready for these and which session you are to attend. Your exercise program will include the following exercises:

RANGE OF MOTION EXERCISES

Lying on your back with a sliding board under your leg. Bend and straighten your hip and knee by sliding your foot up and down the board. Progress to 10 times, 3 times a day.

Sit on a chair with your feet on the floor. Bend your operated knee as much as possible. Hold for 20 seconds. Repeat x 10, 3 times a day.

STRENGTHENING EXERCISES

Lie on your back with legs straight. Bend your ankles and push your knees down firmly against the bed. Hold x 5 seconds. Repeat x 10 times. 3 times a day.

Lie on your back. Bend one leg putting your foot on the bed and put a cushion under the straightened, operated knee. Exercise your straight leg by pulling your foot and toes up, tightening your thigh muscle and straightening the knee (keep the knee on the cushion). Hold approx. x 5 seconds and slowly relax. Repeat x 10 times. 3 times a day.

Lie on your back with the operated leg straight and the other leg bent. Exercises your straight leg by pulling the toes up, straightening the knee and lifting the leg 20cm off the bed. Hold approx. x 5 seconds. Slowly relax. Repeat x 10 times. 3 times a day.

USE OF HEAT AND ICE

Ice: Ice may be used during your hospital stay and at home to help reduce the pain and swelling in your knee. Pain and swelling will slow your progress with your exercises. A bag of crushed ice may be placed in a towel over your knee for 15-20 minutes. Your sensation may be decreased after surgery, so use extra care. Heat: If your knee is not swollen, hot or painful, you may use heat before exercising to assist with gaining range of motion. A moist heating pad or warm damp towels may be used for 15-20 minutes. Place these on the thigh muscle. Your sensation may be decreased after surgery so use extra care.

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YOUR GOALS

Independent getting in and out of bed. Independent in walking with crutches or walker on a level surface. Independent walking up and down stairs. Achieve targeted joint range of motion. Achieve required muscle power and be independent with exercise programme.

Adapted from KRAMES Communications

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DAY OF OpERATION

Drain from operation site is in place to clear excess fluid. Pain control. If awake do ankle exercises for five minutes hourly. Deep breathing exercises hourly. Rolled up towel is placed under ankle to keep knee in full extension

Adapted from KRAMES Communications

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DAY 1

Mobilise a short distance with a walking frame and a Physiotherapist plus assistant. May sit out in the chair. Commence exercise programme; - strengthen quadriceps muscles - increase joint range of movement - should have full knee extension Continuous Passive Motion (CPM) machine to increase joint range of motion. Target 0 - 45.

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DAY 2

Mobilise longer distances e.g. to toilet and back with walking frame and the assistance of one. Get out of bed independently CPM - Target 0 - 65 Exercise programme - active knee flexion target 55 - 65

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DAY 3

Progress to walking with sticks/crutches, with the assistance of the Physiotherapist Increase walking distance with frame or sticks e.g. around nurses station or up and down the corridor. CPM (if necessary) - Target 0 - 80 Exercise programme - Can straight leg raise - Active knee flex target 70

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DAY 4

Mobilise independently with sticks/crutches up and down corridor. Stairs with physio CPM (if necessary) target 0 - 90 Exercise programme - Active knee flex target 80 - 90

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DAY 5

Independent on stairs. Independent in and out of bed. Increase distance on sticks/crutches. May have a shower once dressing has been changed. Exercise programme - can do straight leg raise - Target 100 knee flexion May go home

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WHEN CAN I LEAVE HOSpITAL?

Most people are able to climb stairs and are ready to leave hospital on Day 5. You may also be offered outpatient physiotherapy if this will help to improve your recovery. You will also be given an appointment to attend with your consultant 6 weeks after the operation. This is for a routine check-up which will make sure you are progressing satisfactorily.

WHAT HAppENS AFTER I GO HOME?

Medication You will continue to take medications as prescribed by your doctor. You may be sent home on prescribed medications to prevent blood clots. You will be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises. Preventing pain is easier than chasing pain. If pain control continues to be a problem, call your doctor.

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WHAT HAppENS AFTER I GO HOME?

Activity Continue to walk with crutches/frame. Bear weight and walk on the leg as much as is comfortable. Walking is one of the better kinds of physiotherapy and for muscle strengthening. However, walking does not replace the exercise program which you are taught in the hospital. The success of the operation depends to a great extent on how well you do the exercises and strengthen weakened muscles.

If excess muscle aching occurs, you should cut back on your exercises.

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OTHER CONSIDERATIONS
You can usually return to work within two to three months, or as instructed by your doctor. You should not drive a car until after the 6-week follow-up appointment. Continue to wear elastic stockings (TEDS) until your return appointment. When using heat or ice, remember not to get your incision wet before your staples are removed.

YOUR INCISION
Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. Your GP will take out any stitches (sutures) somewhere between 9-14 days. On discharge you will be given a pack for the GP and advised when to make your appointment.

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PREVENTION OF INFECTION
If at any time (even years after the surgery) an infection develops such as strep throat or pneumonia, notify your physician. Antibiotics should be administered promptly to prevent the occasional complication of distant infection localizing in the knee area. This also applies if any teeth are pulled or dental work is performed. Inform the general physician or dentist that you have had a joint replacement.

WHEN DO I RETURN TO THE CLINIC?

Your first return appointment is usually 6 weeks after discharge, at which time you will be examined and have x-rays. Subsequent appointments may be at 6 months, one year, or two years after surgery.

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STAIRS TECHNIQUE
Going Up-Stairs Maintain crutches/walking stick on the step below Lead with the unoperated leg up onto the step above Take your weight onto the unoperated leg by pushing on crutches/ walking stick and banister Follow with the crutch/walking stick onto the same step

Going Downstairs Put crutch/walking stick down onto the step below Follow with the operated leg Take weight onto the operated leg using the crutches and banister for support Follow with the unoperated leg onto the same step

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GLOSSARY
Anaesthetic - a drug which removes sensation. Epidural - this term is often used to describe an injection given around the area of the spinal nerves to anaesthetic the lower half of the body. The full name is epidural blockade. Prosthesis - an artificial body part. An artificial knee joint is one example Revision Surgery - when the same operation has to be repeated.

ADApTED FROM :

The American Academy of Orthopaedic Surgeons, July 2001. Data bases courtesy of the Irish Society of Chartered Physiotherapists (ISCP) and the UK Chartered Society of Physiotherapy (CSP). Arthritis Research Campaign. (For further information contact www.arc.org.uk)

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NOTES

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NOTES

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The Galway Clinic, Orthopaedic & Sports Physiotherapy Doughiska Co. Galway, Ireland Phone: +353 (0)91 785 450/457 Fax: +353 (0)91 785 453 E-mail: physio@galwayclinic.com Make your next appointment online @ www.galwayclinic.com