Total Knee Replacement Unicompartmental Knee Replacement eBook

Wellness & Lifestyles Australia

TOTAL KNEE REPLACEMENT (TKR) & UNICOMPARTMENTAL KNEE

REPLACEMENT (UKR) E-BOOK

prepared by Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE .................................................................................................................1 INTRODUCTION ......................................................................................................................2 KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY..........................................................3

Anatomy .................................................................................................................... 3 Degeneration............................................................................................................... 3 Indications for surgery.................................................................................................... 3

PREOPERATIVE ADVICE AND PLANNING ..........................................................................................4 Before the surgery ........................................................................................................ 4 After the surgery .......................................................................................................... 4

OPERATION PROCEDURE............................................................................................................ 5 Total knee replacement.................................................................................................. 5 Unicompartmental knee replacement ................................................................................. 5

ACUTE INPATIENT PHASE (WEEK 1) ...............................................................................................6 Goals......................................................................................................................... 6 What to do.................................................................................................................. 6 What youll notice......................................................................................................... 6 Exercises .................................................................................................................... 7

OUTPATIENT PHASE (UP TO 3-4 MONTHS) ..................................................................................... 11 Hydrotherapy..............................................................................................................13 Stationary bike riding....................................................................................................17 Exercises on land .........................................................................................................17

SUMMARY ........................................................................................................................... 23 CONTACT US ....................................................................................................................... 24

MANUAL LAST MODIFIED 2/8/2010

http://www.wellnesslifestyles.com.au Ph: +61 8 8331 3000 Fax: +61 8 8331 3002

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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INTRODUCTION Welcome to the W&L series of eBooks. You have chosen the edition on total knee replacement (TKR) and unicompartmental knee replacement (UKR) rehabilitation. This resource will be beneficial to anyone who: Anyone who is interested in the anatomy and biomechanics of the knee joint Anyone who has knee degeneration problems and is wondering what surgery involves Anyone who is going to have a TKR or UKR and wants to be able to prepare themselves and know what

to expect in advance Anyone who is participating in a TKR or UKR rehabilitation program and wants a comprehensive guide

to their exercises Anyone who is providing a rehabilitation program and wants up to date information with all the

important details This eBook will cover information about the anatomy of the knee, provide an explanation about the degenerative process of the knee joint and discuss the alternatives to surgery as well as explaining when it is best to choose surgery. It also will accompany you from the weeks leading up to surgery until you return to your normal routine with advice, answers and exercises. The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.


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KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY

Diagram taken from: VeriMed Healthcare Network (2005), Knee Arthrosscopy Series, Discovery Health, Accessed 1st August 2010

http://healthguide.howstuffworks.com/knee-arthroscopy-series-picture.htm

Anatomy The knee joint has two parts, the patellofemoral and the tibiofemoral joints. The patellofemoral joint is between the knee cap (patella) and the femur bone. The femur has a groove at the front which the patella sits in and is able to slide up and down when the knee bends and straightens. The tibiofemoral joint is the main one, between the femur and tibia. The joint surface of the tibia (the shin bone) is relatively flat and has articular cartilage and menisci covering the bone. The femur (thigh bone) is rounded to allow for a rolling movement on the flat tibia and also has articular cartilage. There are large muscles and ligaments surrounding the knee joint to keep the joint secure and transmit weight through the tibiofemoral evenly.

Degeneration Through muscle imbalances in strength or length, trauma, rheumatoid arthritis or general wear and tear the joint surfaces can degenerate away. There are many reasons which can cause joint surfaces to wear away but the general process involves the bone joint surfaces being exposed and rubbing together which can be painful. Sometimes the inner (medial) or outer (lateral) compartment of the knee wears before the other so there is arthritis in only one sided.

Indications for surgery The main reason for surgery is if the there is a large degree of degeneration in the knee joint which cant be successfully managed with other treatments such as physiotherapy, medications, weight modification or activity modification. A total knee replacement (TKR) or unicompartmental knee replacement (UKR) will help Reduce pain Increase stability and mobility Improve the knees functional abilities Correct alignment or any deformities.


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PREOPERATIVE ADVICE AND PLANNING

Before the surgery

Check with your doctor which medications you should be taking in the lead up to your surgery, there may be some ones you take regularly which you have to stop or some antibiotics you will need to start taking before you have the TKR or UKR.

You may wish to donate some of your own blood for the operation although there is the option to use blood donated for transfusions.

Once you admitted into hospital you will most likely have to go through a screening examination including x-rays, blood tests, cardiograms and a physical examination.

You will have to fast at least 12 hours before your surgery. During your last shower before the operation, you will have to use a special soap to wash yourself

and give special attention to your knee which is going to have the replacement. There is a choice available for anaesthetic, some will make you unconscious during surgery while

others can be used to numb only your lower half. You will have an opportunity to discuss these options with your anaesthetist and surgeon.

After the surgery

You will notice that your knee retains some warmth and swelling for some weeks after your surgery.

The early stages of rehabilitation will be crucial for regaining movement in your knee before it fully heals.

Your exercises which cause discomfort arent at risk of damaging your knee and are important for gaining function in the long term.

You will need some assistance with walking at first (usually using a walking frame or walking stick as you improve) but will usually be able to walk independently by 6 weeks after surgery.

With driving, if you have a TKR or UKR on your left knee and drive an automatic you should be able to recommence driving immediately. Otherwise, it usually takes about 4 weeks before you will be comfortable enough to drive.

Sexual activity is also appropriate when comfortable. In order to protect yourself and your knee after surgery it is best to avoid

Activities with quick movements which may stress your knee through twisting, impacting, kneeling or stop-starting.

Putting a lot of weight through your knee while it is bent (like walking up a steep incline or stairs). Carrying heavy objects or gaining weight. Having to bend down to low chairs or toilets


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OPERATION PROCEDURE

Total knee replacement The procedure takes approximately 2 hours. An incision is made at the front of the knee and quadriceps muscle detached from the patella so that it can be moved aside and the tibiofemoral joint is exposed. The joint surfaces of both the femur and tibia are removed to allow for the prosthetic parts to be inserted. The following components are used in a TKR to replace joint surfaces:

A metal femoral component is either cemented or impacted into the end of the femur to replace its joint surface.

A metal tibial component has a stem which anchors down into the top of the tibia bone and replaces the weigh bearing surface of the tibia.

A plastic cover is used to cover the tibia components joint surface to help absorb force, similar to articular cartilage, and allow the femur and tibia to move smoothly on each other.

In some cases a plastic button is placed over the back of the patella if it has a high level of degeneration to help it move smoothly over the front of the femur.

Diagram taken from:

(2009), Jumpers Knee Patellar Tendinopathy, Health 2 Sport, Accessed 1st August 2010 http://www.health2sport.com/category/sports/knee-injury-sports/

Unicompartmental knee replacement This surgery follows a similar procedure to a TKR but only the patellofemoral joint or the inner or outer part of the tibiofemoral joint is replaced. Usually this surgery means having a smaller incision and quicker recovery due to the smaller degree of trauma experienced by the tissues surrounding the knee.


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ACUTE INPATIENT PHASE (WEEK 1) After your surgery you will be given instructions about exercises for rehabilitation. This procedure usually gives excellent improvements in functional ability such as using stairs, driving and all other activities of daily living. This outcome relies on improvements made in the early stages of rehabilitation and diligence with exercises.

Goals The main goals for this first week are to be able to: Fully straighten your knee and bend it past 90 (with the help of your hands) Be able to use your quadriceps muscle to control your knee (see quadriceps control exercise) Walk normally with the help of a walking stick or walking frame Be able to do your exercises on your own

What to do Elevate your operated leg with a pillow under your calf to reduce the accumulation of swelling in your

knee. Ice the knee and paddle your feet to help swelling to resolve. Massage your thigh, calf, the sides and back of your knee with moisturising cream. Your leg may be put on a continuous passive movement (CPM) machine which will bend and straighten

your leg for you but try and contribute to the movement yourself. This may be done for 2-3 hours a day.

What youll notice Youll be monitored regularly for blood pressure, heart rate and temperature as well as movement

and sensation in your operated leg. There will be at least one drain situated in your knee which will be taken out 1-2 days after surgery. You will continue to have fluids delivered through your veins as well as other medications for a couple

of days. Youll be given tubigrip (like a bandage) in place of your dressing with T.E.D. (Thrombo Embolic

Deterrent) stockings which are used to stop blood clots forming in your leg while you arent using it as much. Keep these on for the six weeks (remove only for washing) or as otherwise instructed.

Youll get out of bed the first day after surgery with assistance from hospital staff and will try walking on the second, usually with a wheelie frame but then progressing to crutches or walking stick.

You will feel tired and walking will be challenging so it is more important to conserve your energy for completing your exercises.

Youll be in hospital for usually 3 7 days. It will take 3 4 months for a full recovery so form your expectations with this in mind.


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Exercises These can be started straight after the operation in bed. Ankle pumping: Do 10 every hour.

Repeat the following exercise session twice a day: Quadriceps control: Contract the quadriceps muscle on the top of your thigh to push the back of your knee into the bed. Hold for 5 seconds and repeat 5 times.


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Knee flexion: Use your hands to help slide your heel towards your bottom until you start to feel an increase in pain. Stop and hold this position for 20 seconds and repeat 10 times.

Knee straightening in bed: Rest your ankle on top of a rolled up towel or some other support and relax your knee so that it straightens out fully, hold for 2-3 minutes. Note: It is very important to regain your ability to straighten your knee early on in the rehabilitation. At first, this exercise may cause pain but it wont cause any damage to your knee.

Inner range quads exercise: Using a rolled up towel under your knee, contract your quadriceps muscle to lift your foot off the bed. Ensure that your leg is straight and you are pushing the back of your knee into the rolled up towel. Gently lower again and repeat 10 times.


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Straight leg raise: With the rolled towel under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Knee bending on chair: While sitting on a chair try to bend your knee as much as possible, using your other foot to help push it under and hold for 20 seconds. Relax your leg and repeat 10 times.


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Knee straightening over chairs: While sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and relax, holding your knee out straight for as long as possible. Aim to build up to 10 minutes at a time. Once again, this exercise will hurt but is very important for a full recovery and wont damage your knee. Use a distraction like TV or have a conversation to make this exercise easier.

Calf stretch in bed: Sit with your leg outstretched and a band (a belt or towel would be fine) around your foot. Straighten your knee and pull your foot towards you until you feel a stretch and hold for 20 seconds.

Walking: Hold the walking stick in the opposite hand to your operated side. When you plant your operated leg, focus on contracting your quadriceps and buttock muscles to keep

your knee straight. Focus on bending your knee when your leg swings backwards. Aim to do short walks frequently at first. When you return home, the incidental walks you do around

the house should be sufficient and longer walks arent required.


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OUTPATIENT PHASE (UP TO 3-4 MONTHS) This part of rehabilitation is expected to continue for up to 4 months as the knee is still healing and adjusting. For this reason, it is very important to keep working on your exercises and aim to straighten your knee because as time goes on it will be harder to make these changes. Continue to see your physiotherapist, especially if you develop new pains as they will be able to help treat your symptoms. At this stage it is important to keep up

Massaging tender areas around you knee. Using ice when your knee becomes hot or has excess swelling, especially after exercise. Elevating the leg when you rest to help reduce swelling. Walk in moderation and be sure to rest when you notice excess heat, swelling or aching.

When getting in and out of chairs, try not to rely on hands but focus on contracting your buttock muscles to lift yourself out of the chair. It will help to shuffle to the front of the chair first and lean forward like your nose is approaching your knees.


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When managing steps or stairs, it is important to rely on your buttock muscles to perform the movement and not by pulling yourself with your arms. Early on, the easiest pattern to manage stairs is: good leg first when going up and operated leg first when going down. As you become stronger and more confident you can reverse this pattern so that your operated knee becomes more reliable.


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Hydrotherapy Doing exercises in the water are a great way to strengthen the knee muscles without putting too much pressure through the joint. As well as strengthening the muscles around the knee, it is important to focus on technique and control when doing all your exercises so that your brain has practice in controlling your knee during movements. A hydrotherapy program is started around 2 weeks after the operation. Use this program as a guide but it is recommended to consult your therapist for specific exercises and intensities. Warm up:

Walking forwards, sideways and backwards, 2 laps each. By the edge of the pool to hold on: Marching on the spot, 20 steps

Bringing your heel to your bottom, 20 times


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Forward and backward pendular swings (floating your leg up in front of you and then swinging it in a

backward direction as far as you can manage) 20 times

Sideward leg swings (lift your leg out to the side trying to keep your trunk still) 20 times

Squats, 10 times (do this exercise on one leg when you gain strength and confidence)


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By the steps: Step up leading with operated leg and step down leading with non operated leg (this is the opposite to

the stepping order on land), 20 steps


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With a floating cuff: Attach the floating cuff to your operated foot to assist with these stretches Quadriceps stretch: stand tall and bend the knee of your operated leg behind you until you feel a

stretch in the front of your thigh. Hold for 30 seconds and repeat twice more.

Hamstring stretch: stand tall and raise your operated leg straight in front of you while keeping your trunk straight. Feel the stretch at the back of your thigh or in your knee and hold for 30 seconds and repeat twice more.

Cool down:

Walking forwards, sideways and backwards, 2 laps each.


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Stationary bike riding Bike riding is a safe way to stretch your knee and increase the amount it is able to bend. Begin with the seat adjusted up high and no resistance on the wheel. Try to push the pedals and complete a full cycle, if you can do the full cycle then lower the seat so

that you are unable to complete a cycle. Push the pedals so that your operated knee is bent and you can feel like it is at the end of its range,

holding the stretch for 20 seconds. Push the pedals backwards to release the stretch and then repeat 5 times.

Exercises on land Repeat this program twice a day: Knee straightening over chairs: Perform this exercise the same as you did in the acute phase. While sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and relax, holding your knee out straight for as long as possible.


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Straight leg raise: Perform this exercise the same as you did in the acute phase. With the rolled towel under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Standing: While standing focus on holding yourself tall with symmetry. Keep feet parallel, contract your quadriceps and buttock muscles to control your lower half and raise your chest to make yourself tall. Hold this posture for 2 minutes, especially after youve been sitting down for a while.


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Calf stretch over step: While holding onto a surface (such as a kitchen bench), have the balls of your feet on a step or phonebook and your big toes together. Drop your heels down, keep your knees straight and tuck in your bottom so that you feel a stretch in your calves. Hold this for 30 seconds and repeat 3 times.

Knee flexion: Perform this exercise the same as you did in the acute phase. Use your hands to help slide your heel towards your bottom until you start to feel an increase in pain. Stop and hold this position for 20 seconds and repeat 10 times.


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Knee bending on the edge of a chair: While sitting on a chair tuck your feet under the chair. Shuffle forward on the chair until you feel an increase in pain in your knee and hold for 30 seconds. Relax your leg and repeat 10 times.

Knee bending stepping on a chair: Step your foot onto a chair and lean forward so that you bend your knee and feel a stretch. Hold for 30 seconds, lean back to release the stretch and repeat 10 times.


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Quadriceps stretch on your tummy: Lying on your tummy have a band hooked around your operated leg and over the shoulder opposite to your operated side (e.g. left foot and held over your right shoulder) and pull so that you feel a stretch at the front of your thigh. Hold for 30 seconds and repeat 3 times.

Balancing on one leg: Standing while holding onto supports (for example, chairs either side) shift your weight over to your operated leg and lift your good leg up. When you feel confident, lift your hands one at a time and count how long you can hold it. Continue daily until you can hold your balance for more than 20 seconds.


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Weight transfer in lunge: Stand with your operated leg in front and knee slightly bent, put most of your weight through your operated leg. Check that your hips and shoulders arent twisted or tilted and that your belly button is directly in line with your big toe. Hold this position for 5 seconds and then step forward with your good leg. Repeat this step 5 times to form a new walking pattern.


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SUMMARY In summary, degeneration of the knee joint can occur for many reasons and can be managed through

activity modification, physiotherapy and medications. However, for cases where other interventions

havent been successful, TKR or UKR are available to treat symptoms and have excellent results.

Early rehabilitation will be important for gaining full function back in the knee. Even if there is some pain

with exercise this is not dangerous for your new joint. The more you push yourself in your rehabilitation

the better your long term functioning will be. A full recovery is expected in 3 4 months after surgery

where you can expect to resume your normal activities with less pain, stiffness and general restriction

from your knee.

Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist.

All the best for a speedy recovery,

W&L team.


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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 08 8331 3000 F: +61 08 8331 3002 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules

Total Knee Replacement Unicompartmental Knee Replacement eBook

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