DR. VIPUL SHARMA, MEMBER, DELHI COUNCIL OF PHYSIOTHERAPIST. REG NO. PR 2649.

1. OSTEOARTHRITIS(OA)
 It is a degenerative joint disease.
 The aetiology is multifactorial still not understood but commonly it
is thought to be wear and tear of joints as one ages.
 Two types :
 PRIMARY OA: This occurs in a joint. It occurs in old age,
mainly in weight bearing joints(knee and hip).
 SECONDARY OA: congenital mal development of a joint,
irregularity of joint surfaces, mal alignment, obesity and

2. excessive weight.
CLINICAL FEATURES
The disease occurs in elderly people, mostly in the major joints of the
lower limb, frequently bilaterally.
 Pain
 Swelling
 Crepitus
 Stiffness
 Muscle spasm
 Capsular contracture
 Incongruity of the joint surface contribute to it.
On examination ,
 Tenderness on the joint line.
 Crepitus on moving the joint.

3.  Irregular and enlarged looking joint due to formation of peripheral
osteophytes.
 Deformity – varus of the knee
 Effusion
 Terminal limitation of joint movement.
 Subluxation detected on ligament testing.
 Wasting of quadriceps femoris muscle.
INVESTIGATIONS
Radiological examination:
Figure: x-rays of the knee , AP and Lateral views, showing
osteoarthritis of knee.
 Narrowing of the joint space.
 Subchondral sclerosis: dense bone under the articular surface.
 Subchondral cysts.

4.  Osteophyte formation.
 Loose bodies.
 Deformity of the joints.
TREATMENT
METHODS OF TREATMENT
 DRUGS: Analgesics are used.
 VISCOSUPPLEMENTATION: Sodium hylarunon has been
introduced. It is injected in the joint 3-5 times over weekly
interval. It is supposed to improve cartilage function.
 SUPPORTIVE THERAPY:
i. Weight reduction.
ii. Avoidance of stress and strain.
iii. Local heat provides relief of pain and stiffness.
iv. Exercises for building up the muscles controlling the joint
help in providing stability to the joint.
v. The local application of counter irritants.
 SURGICAL TREATMENT
i. Osteotomy.
ii. Joint replacement.
iii. Joint debridement.
iv. Arthroscopic procedures.

5. KNEE REPLACEMENT
Due to rise in knee joint osteoarthritis, there is a rise in cases of knee
replacement surgeries. The knee replacement is also known as knee
arthroplasty. It is of two types:
 Partial Knee Replacement.
 Total Knee Replacement(TKR).

6. During knee joint replacement surgery, damaged cartilage and bone are
removed from the knee joint. Man-made (artificial) pieces, called
prostheses, are then placed in the knee.
These pieces may be placed in up to three surfaces in the knee joint:
 Lower end of the thigh bone. This bone is called the femur. The
replacement part is usually made of metal.
 Upper end of the shin bone--the large bone in your lower leg. This
bone is called the tibia. The replacement part is usually made from
metal and a strong plastic.
 Back side of your kneecap. Your kneecap is called the patella. The
replacement part is usually made from a strong plastic.
You will not feel any pain during the surgery because you will have one
of these two types of anesthesia:
 General anesthesia. This means you will be asleep and unable to
feel pain.
 Regional (spinal or epidural) anesthesia. Medicine is put into your
back to make you numb below your waist. You will also get
medicine to make you sleepy. And you may get medicine that will

7. make you forget about the procedure, even though you are not
fully asleep.
After you receive anesthesia, your surgeon will make a cut over your
knee to open it up. This cut is often 8 to 10 inches long. Then your
surgeon will:
 Move your kneecap (patella) out of the way, then cut the ends of
your thigh bone and shin (lower leg) bone to fit the replacement
part.
 Cut the underside of your kneecap to prepare it for the new pieces
that will be attached there.
 Fasten the two parts of the prosthesis to your bones. One part will
be attached to the end of your thigh bone and the other part will be
attached to your shin bone.
 Attach both parts to the underside of your kneecap. A special bone
cement is used to attach these parts.
 Repair your muscles and tendons around the new joint and close
the surgical cut.
The surgery usually takes around 2 hours.
Usually, artificial knees have both metal and plastic parts. Some
surgeons now use different materials, including metal on metal, ceramic
on ceramic, or ceramic on plastic.

10. ROLE OF PHYSIOTHERAPY
Physiotherapist plays an equally important role as the surgeon
performing the surgery. This is due to the fact that surgeon replaces a
knee joint but the soft tissues i.e. ligaments, muscles, and myofacia
requires a tissue-level engineering to gain a pain free , fully functional
knee joint, which will be done by the physiotherapist after the surgery.

11. When to go for the knee replacement?
The foremost indication to undergo a knee replacement surgery is the
pain that is immense and disabling i.e. it is affecting the day to day
activities. This pain along with severe arthritic changes evident on
radiographs requires a planned knee replacement surgery. But before
undergoing knee replacement, the following conservative treatment can
be considered:
 NSAIDs
 Physiotherapy treatment for atleast one month.
 Lifestyle modification and ambulatory aids, for example, cane,
leaving cross-legged sitting, use of western commode etc.
 Early surgical intervention- steroid injection, arthroscopic
debridement etc as per the consultant surgeon advice.
OUTCOMES: KNEE REPLACEMENT
After an initial period of extensive physiotherapy and rehabilitation
(say about 2-3 months), a person can expect a pain free knees, a
normal pattern of walking that also allows the patient to ascend or
descend the stairs ( although stair climbing should be restricted after
total knee replacement). Along with this, the person will be able to do
all activities of daily living. Cross- legged sitting is generally not
advisable (some implants offer that opportunity also).
Post – operatively knee flexion range of 90 degrees should be attained
for normal activities of daily living. But 105 degrees to 110 degrees
of knee flexion range is required.

12. REHABILITATION PROCEDURE: KNEE
REPLACEMENT
EARLY GOALS OF PHYSIOTHERAPY
 Following the knee replacement surgery, there must be rapid
mobilization of the patient to avoid the complications of bed
rest i.e. DVT (Deep vein thrombosis), pulmonary embolism,
pressure ulcers, bed sores.
 O-90 degrees of knee ROM in the first two weeks of
arthroplasty ( except mention by surgeon). Along with this ,
complete extension should be achieved in the operation room
following surgery. And rehabilitation procedures should take
care to maintain that range.
 Rapid return of quadriceps strength. And knee musculature
strengthening.
 Learning safe transfers and ambulation.
 Independent walking with an assisted device.
NOTE: In case of complex knee arthroplasty
involving osteotomies or other procedures
simultaneously, the patient may be non weight
bearing for a longer duration.

13. PRE OPERATIVE PHYSIOTHERAPY
Pre – operative physiotherapy plays a very important role in successful
outcome of TKR. 2-5 pre –operative physiotherapy sessionsn should be
undertaken before going for arthroplasty. Benefits of pre- operative
physiotherapy includes:
 This will help patient to learn all the exercises that they needs to do
following surgery. Learning of execises will be somewhat difficult
after the surgery due to pin, knee stiffness.
 Learn to walk with the walker, ascending and descending of stairs
with stick and other transfers.
 Making the patient aware of the overall procedure and initial pain
after the surgery that may stay for a few weeks. In many cases,
when pre- operative PT sessions have not considered.
 Learn to use cold packs.
 Avoid placing a pillow below the knee while resting, avoid putting
excessive load on the replaced knee by trying to walk without
walker, unless it is advised.
Post operative physiotherapy
This phase of post- operative PT is generally covered in hospitals
and thus no elaborations are required here. Main points include:
 Maintaining complete extension range.
 Minimizing the effects of bed boundation by early
ambulation.
 Minimizing edema in lower limb especially at ankles and
knees.

14.  Minimizing inflammation at knees by use of cold packs.
 Gait training and stair ascending/ descending.
EARLY WEEKS(2ND
TO 8TH
WEEK)
This is the most challenging rehabilitation period for the PT
following knee replacement surgery. This is the phase that
decides the outcomes of the surgery. In this phase,
physiotherapy should be continued at home under the guidance
of a well qualified physiotherapist.
MAJOR GOAL INCLUDE:
 Increasing the flexion range to 90 to 120 degrees
depending upon the requirements, ability of the client and
other post surgical factors.
 Keeping the post surgical pain to the minimal level.
 Helping the client learn the use of western style toilet seat.
 Rapid increase in strength of quadriceps, hamstrings and
gluteal muscles( hip musculature)
 Normal scar mobility.

15. PHYSICAL THERAPY AND EXERCISES
Following your surgery, you will have many weeks of physical
therapy (PT) to
help ease your operated knee back into activity. PT is an integral
part of your
recovery and is very important in determining the outcome of your
surgery.
We have a list of commonly used exercises, but your surgeon and
physical
therapist will prescribe a specific set of exercises that is best for your
unique case.
These exercises are important to your overall recovery – preventing
blood
clots, improving circulation, improving flexibility and knee
movement and
strengthening muscles. While they may feel uncomfortable at first,
they will

16. become easier with time and help you return to normal activity.
 Ankle Pumps
 Quad Sets
 Short Arc Quads (Terminal Knee Extension)
 Heel Slides (Hip & Knee Flexion)
 Long Arc Quad (Knee Extension & Flexion)
 Straight Leg Raises
a

17. b c
d
e

18. Dr. Vipul Sharma, Reg.No. PR 2649
B.P.T., CMT ( ORTHO AND SPORTS), MIAFT, MDCPT,
BYT.
CONSULTANT PHYSIOTHERAPIST
MEMBER, DELHI COUNCIL OF
PHYSIOTHERAPIST, GOVERNMENT OF NCT OF
DELHI.
Ex- Physio , Tejasvini Multispeciality Hospital,
Orthopaedics and Trauma Centre, Mangalore.
Visiting Consultant Physio, Yenepoya Hospital,
Mangalore.
Physio, Arya Physiotherapy Centre, New Delhi.

19. Contact: +91 9999989492
Email: vipulsharmaa@hotmail.com
THANK YOU