4. Introduction
Total knee arthroplasty is (TKA) is also called
as total knee replacement (TKR).
It is an advance procedure done in older
patient having age >70 yrs.
Patients with knee osteoarthritis under go for
TKR.
The main goals for TKR are to relieve pain
and improve a patient’s physical function and
quality of life.
5.
6. Indication for surgery
Severe joint pain with weight bearing or
activity which causes pain.
Extensive destruction of articular cartilage.
Marked deformity of knee such as genu
varum/valgum.
Gross instability or limitation of motion.
Failure of non-operative management or
previous surgical procedure.
7.
8.
9. Contraindication
Poor general health
Severe osteoporosis
Recurrent or current joint sepsis
Neuropathic arthropathies
Quadriceps insufficiency
Flexion deformity of more than 60 degree
combined with varus & valgum
Hyperextension more than 20-30 degree
11. Unicompartmental implants
These are used to replace the opposing articular
surfaces of the femur & tibia of either the medial or
lateral compartment of knee.
The opposite compartment & the patello femoral
compartment remain into it.
This implant are all of unconstrained type.
12. Bi-compartmental implants.
These are used to replace the opposing articular
surfaces of the femur & tibia of both the medial or
lateral compartment of knee.
resurfacing the patello femoral joint.
This deficit & mechanical loosening of the implant
have resulted in rejection of this approach.
13. Tri-compartmental implant
These implant not only replace the opposing surfaces of
the femur & tibia both of the medial & lateral
compartment but also provide for resurfacing the patello-
femoral articulation.
Implants can be divided conveniently into 3 groups
according to the degree of mechanical constraint
provided.
14. 1.Unconstrained prosthesis
They are primary resurfacing implants.
Few implants in this category may provide
minimal restrain to rotation or translation.
Prosthesis greatly depends on the integrity
of the soft tissue to provide jt stability.
Soft tissue balancing is necessary to
achieve it stability while restoring proper
limb alignment.
Eg:- Toconley & PCA
15. 2.Semiconstrained prosthesis
Largest no of prosthesis fall in this category.
The degree of constrain possed by a given prosthetic
design varies from almost minimal to an extent only
somewhat less than in a fully constrained design.
Combination of soft tissue release a proper prosthetic
selection may achieve a stable joint, muscle limb
alignment & correction of deformities like flexion
contracture of upto 45 degree & angular deformities of
20-25 degrees.
Angular deformities associated with ligamentous laxity
are more easily corrected than fixed angular
deformities.
16. 3. Fully constrained prosthesis
They permit flexion & extension in sggital
plane, but prevent adducting & abducting in
the coronal plane.
They are
1. hinged constrained implants
-true hinges
-rotating hinges
17. Procedure
An incision is made
over the front of the
knee and tibia.
Femoral condyles
are exposed.
Bone cuts are made
to fit the femoral
component.
18. Femoral IM Canal
A reamer is passed through a hole near the
center of joint surface of lower end of femur
and into femur shaft
19. Cutting the Distal Femur
Another resection
guide is anchored to
end of femur
Pieces of femur are
cut off the front and
back
As directed by the
miter slots in guide
Then cuts are made
to bevel the end of
femur to fit implant
21. Cutting the Tibial Bone
A resection guide is
attached to front of
tibia
Direction of the
saw cuts in 3D
AP tilt
LM tilt
Upper end of tibia
is resected
22. Placing the Femoral
Component
Metal
component is
held in place by
friction
In the
cemented
variety
An epoxy
cement is
used.
30. Immobilization
Knee is immobilized in bulky compression
dressing for a day or 2 post operatively.
After the bulky dressing is removed a post knee
splint is often worn but is removed for daily
exercises.
Cementless arthroplasty may require a longer
period of immobilization than a cemented
procedure to allow ingrowth of bone into the
prosthesis.
A post knee splint may be indicated for use at
night for as long as 12 weeks post operatively.
31. Complications
Intercondylar fracture
Damage to peripheral nerve (eg. Peroneal nerve)
Infection
Joint instability subluxation
Component loosening
Risk of wound healing
DVT
Deep periprosthetic infection
Patellar instability or tracking
Limited knee flexion
Impaired function of the extensor
mechanism(extensor lag)
32. Physiotherapy management
Pre operative physiotherapy
1) breathing exercises.
2) strengthening exercises.
-teach isometric ex for hamstring, glutei &
quadriceps.
-Resistive ex for ankle & foot on the affected
side are taught.
3) ankle-pump exercises.
4)mobilization exercises.
33. Post operative
The rehabilitation protocol for a patient with
TKR is dependent on following 3 phases.
1) Maximum protection phase.
2) Moderate protection phase.
3) Minimum protection phase.
34. Maximum protection phase
To prevent pulmonary complication
-deep breathing & coughing exercises
-localized and generalized expansion ex to
maintain healthy respiratory system
-if there are secretions in the lungs as aresult
of G.A postural drainage is given.
To prevent vascular complications
-ATM
35. To promote health and reduce post operative
odema & pain.
-strong ankle pumping ex begins immediately
after surgery.
-elevation of foot end to assist venous return to
reduce swelling.
-to relieve pain, TENS may be given at site of
pain.
36. To improve strength of quadriceps
-immediately after sx or as soon as patient can
tolerate, SQE are taught to the patient is
encouraged to practice them frequently in a
day.
-last 15 degree extension can be given
keeping pillow under the knee for quads lag.
-supported SLR is taught as early as possible.
-active knee extension in high sitting should be
started and gradually increase repetation,
which should be started on 5th day after
operation.
37. To maintain the strength of hip muscles
-static & isometric ex for hip muscles and
hamstring muscles.
To improve joint mobility for knee
-cpm is given
-active and active assisted ex for knee
-hold and relax should be started(70 degree
5-12 days)
-knee range must not exceed 40 in first 3 P.O
days as a transcutaneous oxygen tension of the
skin near the incision decreases., if it knee flexion
is >40 it may delay wound healing.
38. To give proper gait training
-the extent to weight bearing is available
dependent upon the type of prosthesis
implanted.
-full weight bearing (12 weeks) & ambulation
without assistive device may not be
permissible for upto 12 weeks P.O
-with cement fixation weight bearing as
tolerated is permissible immediately after
surgery & increased to full weight bearing over
6 weeks.
39. yet patient should continue to use a cane
through
moderate & minimum protection phase of
rehabilitation until adequate strength & stability
are achieved.
isometric ex, rythmical stabilization & weight
transference may be practiced in stand but the
splint as retained for walking until 70-90 of flexion
is achieved.
gait training is commenced initially in parallel
bars & in front of mirror, so that the patient can
see & feel the correct pattern of walking.
gait training can then be progressed with a
walker or crutches.
40. Managing uneven ground & slopes
managing stairs
-within 5-12 days stairs case ascend and
descend maximum to be taught
-ability to climb stairs with alternate steps may
not be possible for some weeks.
41. To make patient functionally independent
-patient is advised not to flex the knee more
than 90 degree. Hence, sitting on floor & cross
leg sitting is avoided.
-patient is advised to use western toilets & can
be made use the toilet as early as he can walk
with an aid.
42. Moderate protection phase
To improve muscular strength
-as healing progresses, multiple angle
isometric resistance ex for quads and hams
can be added.
-adequate strength of knee extensor is most
important for stability of knee during wt.
bearing activities.
-resisted SLR in various position should be
included to increase the strength of hip
muscles.
-as weight bearing permits closed chain, mini
squats, lunges can be added to improve
stability.
43. To increase ROM
-by 3-6 weeks knee flexion ex can be given
depending upon type of implant used
-gentle self stretching or contract relax ex are
also added
-stationary bicycle can be used.
-the cycle first may have the sit position as
high as possible to increase knee flexion, and
the seat can be gradually lowered.
44. To give gait training
-single crutch walking & well assisted stair
activities is encouraged.
-Gait training with which emphasis on feet
knee swinging can be started with a cane and
in progression to full weight bearing by 6
weeks if cemented is done.
-yet patient should continue using single cane
til 12 weeks.
45. Minimum protection phase
By 12th week after surgery, emphasis on
rehabilitation is done on muscle conditioning
so that the patient will have the strength 7
endurance to return to a full level of functional
activities.
-ambulation, stair climbing, & so on are
gradually increased.
46. Expected results
Almost all patient report a significant relief of
pain with knee motion and weight bearing.
Improvement in ROM may continue upto 12-24
months P.O but only minimal changes occur
compared to pre-op status.
It may take 3 months p.o for a patient to regain
strength in quads & hamstring muscles.
