Post op TKR/Bilateral Knee OA
Ahmad Mu'izzuddin Bin Shamsudin
57179313259
Semester 5
Hospital Sultanah Bahiyah
Definition
Osteoarthritis is a condition in which the
natural cushioning between joints and
cartilage becomes wears away .
This condition commonly affects on knee
joints.
Is also know as a degenerative arthritis or
degenerative joint disease.
This condition is called wear-and-tear
arthritis
Anatomy
The knee is one of the largest and most complex joints in the body.
The knee is composed of 4 bones: the femur, tibia, fibula and knee
cap which is patella.
Tendons connect the knee bones to the leg muscles that move the
knee joint.
Ligaments join the knee bones and provide stability to the knee:
-anterior cruciate ligaments
-posterior cruciate ligaments
-medial collateral ligaments
-lateral collateral ligaments
Two C-shaped pieces of cartilage called the medial and lateral
menisci act as shock absorbers between the femur and tibia.
Pathophysiology
Occur at knee joint
Process degenerative or repetitive movement
Inflammation
Reduce synovial fluid and space of bone
Growth of osteocyctes and bone spur
Joint stiffness and movement restriction
Causes
Primary osteoarthritis is mostly related to aging. With
aging, the water content of the cartilage increases and the
protein makeup of cartilage degenerates.
Repetitive use of the joints over the years causes damage
to the cartilage that leads to joint pain and swelling.
Cartilage begins to degenerate by flaking or forming tiny
crevasses.
In advanced cases, there is a total loss of the cartilage
cushion between the bones of the joints.
Loss of cartilage cushion causes friction between the
bones, leading to pain and limitation of joint mobility.
Damage to the cartilage can also stimulate new bone
outgrowths (spurs) to form around the joints
Obesity causes osteoarthritis by increasing the mechanical
stress on the cartilage.
Sign and Symptom
Crepitus.
Pain.
Tenderness.
Stiffness.
Limit range of motion.
Loss of flexibility.
joint swelling/synovitis (warmth, effusion,
synovial thickening)
Bow leg deformity-varus.
Diagnosis
Physical exam
checking for tenderness, swelling , Redness and limits range of motion.
Imaging tests
X-rays.
Magnetic resonance imaging (MRI).
Lab tests
Blood tests.
Joint fluid analysis.
Special tests
Patellar grind test
-positive sign maybe lead to osteoarthiritis of knee
Q angle
Doctor Management
Medication :
Pain relieve such as
Analgesic acetaminophen.
non-steroidal antiinflammatory drugs
(NSAIDs) such as
ibuprofen (Advil, Motrin), or
naproxen sodium (Aleve).
Glucosamine pain relief,
protect the cartilage and
reduce worsening of
cartilage destruction
continue..
Injection :
corticosteroids or hyaluronic
acid into the knee.
-Cortisone is anti
inflammatory
medication.
-Hyaluronic acid is a
injection
that help lubricate the
joint, ease pain ,and
improve
people's ability to get
back.
to some of the activities.
continue..
Surgery :
Total knee replacement
Knee replacement surgery resurfaces the bones at the
top of the shin (tibia) and the bottom of the thigh (femur)
with an implant made of metal and plastic parts.
The top of the shinbone is resurfaced with a metal tray,
or bearing, topped with a medical-grade plastic spacer.
This plastic replaces the cartilage, providing a smooth
surface for the new knee.
An area at the bottom of the thighbone is resurfaced
with a rounded metal part. This piece is designed to
mimic the curve of your natural bone. The undersurface
of the kneecap may also be replaced with a medicalgrade plastic.
continue..
Partial Knee Replacement
A partial knee replacement, surgeon will
replace only the part of knee that is
damaged or arthritic.
Partial knee replacement is a surgical
treatment option that replaces (or
resurfaces) only the damaged portion of
the knee while conserving knee ligaments
and unaffected cartilage.
Physiotherapist management
Passive Treatments for Knee Osteoarthritis
Thermotherapy
Cold therapy
Hydrotherapy
continue..
Active Treatments for Knee
Osteoarthritis
Stretching exercise
-Standing Quadriceps Stretch
-Standing Calf Stretch
Strengthening exercise
-Static Inner Quadriceps
Contraction
-hamstring contraction
Range of motion and Flexibility
exercises
External support devices
Braces:
- total knee braces when being
diagnosed with total knee
osteoarthritis
- lateral elevated orthopedic sole
when being diagnosed with
medial compartment knee
osteoarthritis.
Taping:
-Has proven slightly effective in
decreasing pain in patients with
-patellofemoral osteoarthritis.
Treatment Protocol
Post-operative days 1
Bedside exercise: Ankle pumps, quadriceps sets, gluteal sets, hip
abduction(supine), straight leg raise(if able).
Knee range of motion (ROM): heel slides.
Bed mobility and transfer training(bed to/from chair).
Post-operative days 2
Exercise for active ROM, active-assisted ROM, and terminal knee
extension.
Strengthening exercises(Ankle pumps, quadriceps sets, gluteal
sets, hip abduction(supine), straight leg raise), 1-3 sets of 10
repetitions for all strengthening exercises, twice per day.
Gait training with assistive device on level surfaces and functional
transfer training(toilet transfer, bed mobility).
continue..
Post-operative days 3-5 (or on discharges to rehabilitation
unit)
Progression of ROM with active-assisted exercises and
manual stretching, as necessary.
Progression of strengthening exercises to the patients
tolerance, 1-3 sets of 10 repetition as for all
strengthening exercises, twice per-day.
Progression of ambulation distance and stair training(if
applicable) with the least restrictive assistive device.
Progression of activities-of-daily-living training for
discharge to home.
Assesment
Name : Mrs. J
Age : 72 years old
Gender : Female
Rn no. : ASxxxxxxxx
Date of admission : 22/8/15
Date of referral : 10/9/15
Date of assesment : 10/9/15
Dr. diagnosis : Post op right knee TKR,Bilateral Knee OA
Dr. management : Surgery - TKR done on 25/8/2015
Conservative - on medication
- refer to Physio
Investigation : X ray done on 22/8/15
Subjective Assesment.
Problem : Patient complain of pain at both
knee, noted Right knee is more painful
than the Left. TKR operation was done at
Right knee. Patient also complain pain at
night disrupting her sleep.
Easing
Aggravating
Pain area
Nature of pain : throbbing pain
Aggravating : on movement, 6
Easing factor : rest, medication, 0
24 hours symptom : AM : better
PM : better
Night : worsened
Irritability : High
Current History : Sudden onset pain at both knee
since [Link] is reduced significantly but
came back around 2014. Come to Hospital
Sultanah Bahiyah seeking for treatment. She
was admitted on 22/8/2015. TKR at Right knee
done on 25/8/15 and was discharge on 29/8/15.
Past history : NIL
Past medical history - HPT, Bronchial
Asthma
Family history : sister - Bilateral Knee OA
Surgical history : NIL
Social history
Occupation : Housewife
Nature of Job : Mild housework
Allergic status : NIL
Dominant side : Right
Hobby : cooking
Home environment: 2 storeyed house,
sitting toilettries. staying at first floor room.
Alcoholic/smoking : NIL
Prev. Physio management : NIL
Drug Therapy : On medication for Pain killer,
HPT
Any Chronic Disorder : NIL
General Observation :
An old, moderate sized, Malay woman come to
department by wheelchair accompanied by her
daughter.
Local Observation :
-Redness over Right knee
-Swelling over Right knee
-Plaster over right knee
Palpation
-Tenderness grade III, slight palpate on Right knee
-Oedema, Non-pitting oedema at Right Knee
-Temperature, slightly higher at right knee compare
to the left
Measurement
ROM, knee, patient in [Link].
Right
Movement
Left
Active
Passsiv
e
Active
Passive
Flexion
105
120
120
120
Extension
30
20
20
15
interpretation :1) Lack 5 of Flexion and Lack 20
of Extension Of Right knee
2) Lack 5 of Flexion and lack 15
of extension of Left Knee
Manual muscle testing
Movement
Right
Left
Flexion
4/5
4/5
Extension
4/5
4/5
Interpretation : Reduced Muscle power due
to pain
Muscle Bulk
Muscles
Right
Left
Hamstring
42
44
Quadriceps
39
40
VMO
40
38
Gastrocnaemius
34
33
Soleus
32
32
Interpretation : Muscle wasting due to
prolong disuse
Swelling
Swelling
joint
Right(cm)
Left(cm)
Difference(c
m)
knee
42
39
Interpretation : swelling at Right knee due to
inflammation process
Leg Length measurement
Measurement
Right
Left
Difference(c
m)
true leg length
85
87
Interpretation
: Right leg 90
shortening due
to
apparent leg
87
3
length
mechanical changes
Clearing Test
Hip
Right
Left
moveme
nt
active
passive
active
passive
flexion
AFROM
AFROM
AFROM
AFROM
extensio
n
AFROM
AFROM
AFROM
AFROM
abductio
n
AFROM
AFROM
AFROM
AFROM
adductio
n
AFROM
AFROM
AFROM
AFROM
internal
rotation
AFROM
AFROM
AFROM
AFROM
interpretation
: Range of motion of both hip
external
AFROM
AFROM
AFROM
AFROM
rotation
are normal
Ankle
movement
right
left
active
passive
active
passive
Dorsiflexion
AFROM
AFROM
AFROM
AFROM
Plantarflexi
on
AFROM
AFROM
AFROM
AFROM
inversion
AFROM
AFROM
AFROM
AFROM
eversion
AFROM
AFROM
AFROM
AFROM
interpretation : Range Of Motion of both
ankle are normal
Sensation test : hot and cold - intact
Analysis :
-Pain at right knee due to inflammation process
-Pain at Left knee due to mechanical changes
-Swelling at right knee due to inflammation
process
-Lack ROM of right knee due to pain
-Lack ROM of Left knee due to pain
-Reduced muscle power of both knee due to pain
-Muscle wasting at Right Leg due to prolong
disuse
-Shortening of Right leg due to mechanical
changes
Short term goal
To reduce pain at both knee in 2/52
To reduce swelling at Right knee in 2/52
To improve ROM of both knee in 2/52
To improve Muscle power in 3/52
To improve muscle bulk in 3/52
Long term goal
To improve daily life activity function
To improve Quality of Life
Plan of Treatment
Pain management
Ultrasound
Stretching exs.
Strengthening exs.
Ambulation
Home exs. program
Intervention
SQE
-patient in supine lying.
-therapist put one hand at the popliteal area,ask
patient to push therapist's hand using only the
strength of her knees.
-10 reps with 5secs hold/set
SLR
-patient in supine lying.
-Instruct patient to knee extension and hip flexion.
-ask patient to hold the position for 5 secs. 10
repitition/ set
Mobilising exs.
-patient in supine lying.
-put a gymball between calf and ankle so
knee and hip at 90o
-ask patient to move the gymball forward
and backward.
-for 10 minutes
Home Exs Program
-ask patient to do exs taught regularly at
home
-advice patient to lose some weight
Evaluation
Patient unable to do all the exercise or
treament as planned due to her wound yet
to dry
Patient obeys every command given
VAS remains the same
Re-assessment
re-assess for VAS,swelling,ROM muscle
power and muscle bulk
