A Project on Knee arthoplasty

8/7/2019 A Project on Knee arthoplasty

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************************************************************KNEE ARTHOPLASTY

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ACKNOWLEDGEMENT

First and foremost I would like to thank my PARENTS

whose valuable support gave me courage and confidence

throughout the study.

I take pleasure to express my gratitude to my project guide

Dr.K.Eswar Reddy, MPT. He encouraged and supported me a

lot to do this project. I am thankful to him for the support and

suggestions he has given in the completion of this project

successfully.

I express my sincere thanks to my college principle

Dr.V.Srinivas Sir, MPT for his valuable guidance in completing

the project.

I am very much thankful to my in charge Dr.Veernag

MPT, Rahul Sir MPT, Dr.Bharani Sir MPT andDr.shahanawaz.S.D, MPT for their valuable advices towards this

project.

I have no words to express my gratitude towards my dear

friends who played a key role in completing this project

successfully.

I thank all my classmates and my respected seniors for

being with me while conducting this study.

I thank Mr. bujji our college attender for his co-operation

throughout the course of study.


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CONTENTS1)INTRODUCTION.

2)

ANATOMY3)BIO-MECHANICS.

4)CLASSIFICATION

5)SURGICAL PROCEDURE

6)PHYSIOTHERAPY ASSESSMENT.

7)PHYSIOTHERAPY MANAGMENT

8) AIMS AND OBJECTIVE OF STUDY.

9)TYPE AND DESIGN OF STUDY.

10) PLACE OF STUDY.11) NO.OF SUBJECTS.

12) INCLUSIVE AND EXCLUSIVE CRITERIA.

13) PARAMETERS.

14) MATERIALS.

15) METHODOLOGY.

16) STATISTICAL ANALYSIS.

17) GRAPHICAL REPRESENTATION.

18) CASE STUDIES.

19) DISCUSSION.

20) CONCLUSION, BIBLIOGRAPHY.


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INTRODUCTION

Painful knees are a common problem in the middle-aged and elderlypopulations. There are quite a few treatments for early stage arthritis

that can help alleviate pain, and return people to their daily activities.

As some point, however, painful knees interfere with quality of life to

such a point that something has to change

When treatments such as anti-inflammatory medications, cortisoneinjections, and physical therapy fail to improve the situation, total knee

replacement could be an option.

Soft tissue defects of the knee also require reconstructive surgery may

occur after trauma or following a surgical procedure.

A common procedure that requires reconstructive surgery to achieveadequate soft tissue coverage of the knee is TOTALKNEE

ARTHOPLASTY.

Knee arthoplasty is an operation to construct a movable or mobile joint.Reconstruction must be designed so that the desired functional and

aesthetic results can be achieved using the simplest method availableand with minimal donor tissue or donor site morbidity.

Soft tissue reconstruction can reestablish mobility and joint function. It

will provide dynamic stabilization of the joint, Provide soft tissuecoverage of the prosthesis and fill the dead Space.

Physiotherapy management plays an important role in a knee

arthoplasty cases in pre or post-operatively where the success of the

surgery is depend not only the success of replacement but actualsuccess of arthoplasty patient is after complete mobilization of knee

joint and achieving his daily activities.


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ANATOMY


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lThe knee is the largest and most complex joint of the body.

lThe complexity is the result of fusion of 3 joints in one,

lThey are

1. Femoro tibial

2. Medial Femoro tibial

3. Femoro patellar joints

l It is compound synovial joint.

ARTICULAR SURFACES:

lThe knee joint is formed by

1. The condyles of femur,

2. The condyles of tibia,

3. The patella.

LIGAMENTS:

y Articular capsule

y Ligamentum patellae

y Tibial collateral

y Fibular collateral


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y Oblique popliteal

y Cruciate ligaments (anterior, posterior)

y Menisci (medial, lateral)

y The transverse

y The coronary

1. Articular capsule:

y

It is very thin

y Its having two attachments

(a)Femoral attachment

(b)Tibial attachment

a)Femoralattachment :l

it has 3 special features

Anteriorly It is deficient

Posteriorly attached to intecondylar line

Laterally encloses origin of popliteus

b) Tibialattachment :l It also has three special features

y Anteriorly - it descends along the margins of thecondyles to the tibial tuberosity. Where it isdeficient.

y Posteriorly- attached to the intercondylar ridge.


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y Posterolaterally- Gap behind the lateral condyle for

passage of the tendon of popliteus.

lThe capsular ligament is weak.

l It is strengthened by

# Anteriorly- medial, lateral patellar retinacular.

# Laterally- Iliotibial tract.

# Medially-Expansions from the tendons of sartorius

and semimembranosus.

# Posteriorly- Oblique popliteal ligament.

2.) Ligamentum patellae:

l

This is the central portion of the common tendon of insertion of thequadriceps femoris.

l It is attached -

# Above- Posterior surface of apex of patella.

# Below-Tibial tuberosity.

lThis ligamentum patella is related to the superficial and deep

infrapatellar bursae.

3.) Tibial collateral:

lThis is a long band of great strength.


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lAttachment-

# Superiorly- medial epicondyle of femur.

# Inferiorly- divides into anterior and posterior parts.

lAnteriorpart:

lAttachments:

# Below to the medial border and posterior part of the

medial surface of the shaft of tibia.

# And is crossed below by the tendons of the sartorius,gracilis and semitendinosus.

lPosteriorpart:

lAttachments:

# Medial condyle of the tibia above the groove for thesemimembranosus.

4.) Fibular collateral ligament:

lAttachment:

# Superiorly- to the lateral epicondyle of femur.

# Inferiorly- embraced by tendon of biceps femoris

and attached to head of fibula.

5.) Oblique popliteal:

lThis is an expansion from the tendon of the semimembranosus.

l It runs upwards and laterally, blends with posterior surface of thecapsule.


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lAttachment

#To the intercondylar line and lateral condyle offemur.

# It is closely related to the popliteal artery.

6.) Cruciate ligaments:

l

These are very thick, strong fibrous bands.

lThey maintain anterior and posterior stability of knee joint.

lThere is

# Anterior cruciate ligament.

# Posterior cruciate ligament.

Anterior cruciate ligament:

lBegins from the anterior part of the intercondylar area of the tibia.

l It runs upwards, backwards and laterally.

lAttachment to the posterior part of the medial surface of lateral condyle

of femur.

l it is taut during extension.

Posterior cruciate ligament:

lBegins from the posterior part of the intercondylar area of the tibia.


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l It runs upwards, forwards and medially.

lAttachment to the anterior part of lateral surface of medial condyle of

femur.

l It is taut during flexion.

7.) Menisci:

lThe menisci are two fibrocartilaginous discs.

lThey are shaped like crescents.

lThey divided at the joint cavity partially in to upper and lower

compartments.

lThey deepen the articular surfaces of condyles of tibia.

lThere is

# Medial menisci.

# Lateral menisci.

Medial menisci:

l It is semicircular, being wider behind than infront.

lThe posterior fibers of the anterior and are continuous with the

transverse ligament.

Lateral menisci:

l It is circular.

l `The posterior end of menisci is attached to the femur through twomeniscofemoral ligaments.

lThe tendon of popliteus and the capsule separate this meniscus from thefibular collateral ligament.


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Function of menisci:

# They help to make the articular surfaces more congruent.

# They act as shock absorbers.

# They help to lubricate the joint cavity.

# They give proprioceptive impulses.

8.) Transverse ligament:

l It connects the anterior ends of the medial and lateral menisci.

9.) Coronary ligament:

lThey connect the periphery of each meniscus with the margin of thehead of the tibia.

SYNOVIAL MEMBRANE:

It lines the capsule.

In front it is absent from patella. Above the patella it is prolonged up

wards for 5 cm or more as the suprapatellar bursa.

Below the patella it covers the deep surface of the infra patellar pad of

fat.

A median fold, intrapatellar synovial fold extends backwards from thefat pad to the intercondylar fossa of the femur.


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BURSAE AROUND KNEE JOINT:

lThere is 13 bursae are presented around knee.

y Anterior-4.

y Lateral- 4.

y Medial-5.

Anterior:

i.) Subcutaneous pre-patellar bursa.

ii.) Subcutaneous infra patellar bursa.

iii.) Deep infra patellar bursa.

iv.)

Supra patellar bursa.

Lateral:

i.) Deep to the lateral head of gastronemius.

ii.) Between the fibular collateral ligament and bicepsfemoris.

iii.) Between the fibular collateral ligament and tendon of

popliteus.

iv.) Between tendon of popliteus and lateral condyle of

tibia.


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Medial:

i.) Deep to the medial head of the gastrocnemius.

ii.) Ansarine bursa.

iii.) Deep to the tibial collateral ligament.

iv.) Deep to the semimembranosus.

v.) Occasionally a bursa presents between the tendons ofsemimembranosus and the semitendinosus.

Relations of the knee joint:

Anteriorly:

i.) Anterior bursae.

ii.) Ligamentum patellae.

iii.) Patellar plexus of nerves.

Posteriorly:

i.) At the middle-

a.) Popliteal vessels.

b.) Tibial nerve.

c.) Middle genicular vessels.


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ii.) Posterolaterally:

a.)Lateral head of gastrocnemius.

b.)Plantaris.

c.)Common peroneal nerve.

iii.) Posteromedially:

a.)Medial head of gastrocnemius.

b.) Semi tendinosus.

c) Semimembranosus.

d) Gracilis.

e.) Popliteus.

Medially:

a.)Sartorius, gracilis, and semitendinosus.

b.) Great saphanous nerve and vessels.

c.)Semi membranosus.

d.)Inferior medial genicular vessels and nerve.

Laterally:

a.)Biceps femoris.

b.)Tendon of popliteus.

c.)Inferior lateral genicular vessels and nerve.


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BLOOD SUPPLY:

l It is supplied by anastomosis around the knee joint.

i.) Five genicular branches of the popliteal artery.

ii.) Descending genicular branch of the femoral artery.

iii.)

Descending branch of the lateral circumflex femoral artery.

iv.) Two recurrent branches of the anterior tibial artery.

v.) Circumflex fibular branch of posterior tibial artery.

NERVE SUPPLY:

i.) Femoral nerve.

ii.) Sciatic nerve.

iii.) Obturator nerve.


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MUSCLES PRODUCING MOVEMENTS AT THE KNEE JOINT:

Movement Principle muscles Accessory muscles

i.) Flexion. - Biceps femoris. - Gracilis.-Semitendinosus. - Sartorius.-Semimembranosus. - Popliteus.

-Gastrocnemius.

ii.) Extension. Quadriceps femoris.a.) Vastus medialis. -Tensorfaciaelatae.

b.)Vastus lateralis.

c.) Vastus intermedius.

d.)Rectus femoris

iii) Medial rotation: -popleteus -sartorius-Semi membranosus -gracilis

-Semi tendinosus

iv) Lateral rotation of -biceps femorisFlexed leg


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BIO-MACHANICS


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1. The primary motions of the knee joint are flexion and extension and

to a lesser extent, medial-lateral rotation.

2. These are motions occur about changing but definable axes andserve the weight-bearing functions of lower extremity.

3. The knee joint can also undergo tibial or femoral displacementanteriorly and Posteriorly and some abduction and adduction

through varus and valgus forces.

4. The small amount of antero-posterior displacement and varus andvalgus forces that occur in the normal flexed knee are the result of

joint in congruence and variations in ligamentous elasticity.

5. Excessive amounts of such motions are abnormal and generallyindicate liigamentous incompetence.

Rotation:

y The axis of motion for rotation at the tibio femoral joint is a

longitudinal axis that runs through or close to the medial tibialintercondylar tubercle.

yDuring lateral rotation of the knee joint, the medial tibial

condyle and inter condylar tubercle act as a pivot point.

yWhen knee lateral rotation is produced with the tibial free (openkinematics chain), the medial tibial condyle moves onlyslightly anteriorly on the femoral condyle, while the lateral

tibial condyle moves a large distance Posteriorly on the lateralfemoral condyle.


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y In medial rotation, the direction of motion of the lateral

tibial condyle reverses whole the medial intercondylar

tuberculae and medial tibial condyle continues to acts aspivot.

y In weight bearing (closed kinematics chain), the lateralfemoral condyle moves Posteriorly on the lateral

tibialcondyle in the lateral rotation of the femur andanteriorly on the lateral tibial condyle in the medial

rotation of the femur.

y The Pivot point remains at the medial condyles, with

lateral motion exceeding medial motion.

y The range of knee joint rotation is dependent on theposition of the knee when the knee is in full extension, it is

in the close packed (locked) position and the ligaments are

taut; no rotation is possible.

y The tibial tubercles are lodged in the inter condylar notchand the menisci are tightly interposed between the

articulating surfaces.

y When the knee is flexed to 90 degree, the ligaments arelax.

y The tibial tubercles are no longer in the intercondylarnotch and the menisci are free to move.

y At 90 degree of knee flexion, approximately 60-90 degrees

of either active or passive rotation is considered to bepossible.

ARTHOKINEMATICS:

y The knee is a modified hinge joint that plays an important role in

stabilizing the body in erect posture.


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y The osseous portion of the knee includes femur, tibia, patella and

fibula.

yThe tibio femoral joint is divided into medial and lateralcompartments.

y The function of knee joint primarily depends upon its static and

dynamic stability.

y Static stability by ligaments.

y Dynamic stability- musculo tendinous units and their aponeurosis.

STATIC STABILITY:

y The distal end of femur has medial and lateral condyles.

y They are convex from side to side are separated by an intercondylar

notch.

y The proximal end of tibial condyles is concave form side to side,

they are separated by medial and lateral intercondylar eminence or

tibial spine.

y This gives static stability of knee in extension, fibrous capsule

provides covering to the joint.

DYNAMIC STABILITY:

y It is provided by condyles of femur and tibia.

y

Strong ligaments.

y Powerful muscles.

y Medial and lateral menisci.


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EXTENSOR APPARATUS:

y Patella.

y Six extensor muscles and quadriceps femoris tendon.

y Patello-femoral and patello-tibial ligaments.

y Patella bursa and fat pads in intra patellar and supra patellar regions.

y Synovial membrane and capsule in antero -medial and antero-lateralportion of joint.

PATELLA:

y Provides dynamic stability of the knee during varied movements.

Extension group of muscles:

The critical strength and support in necessary for extension

mechanism is provided by quadriceps.

The selective action of there attachments provides varying

degree of dynamic stability.

Knee is most stable when locked in full extension byaction of quadriceps femors.

PATELLO-FEMORAL AND PATELLO TIBIAL LIGAMENTS:

lMainly offers stability to patella.

lPatella bursae and fat pads:

They are the action of extension mechanism by reducingfunction.

lSynovial membrane:

It provides lubrication to movements.


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Axial rotation:

y

Automatic rotation (locking) of the knee joint can be differentiatedform axial rotation of knee that occurs in knee flexion. Both themovements take place in transverse plane motions around a vertical

axis.

y Axial rotation is due to joint in congruence and ligamentous laxity.

y Automatic rotation is obligatory, produced by asymmetry of surfaces

and ligmentous tension.

MUSCLES:

FLEXORS:

y There are seven muscles that flex the knee. The knee flexors are thesemimembranosus, semitendinosus, biceps femoris, sartorius,gracilis, popliteus and gastronemius muscles.

y All the flexors are two joint muscles except short head of biceps

femoris and the popliteus.

EXTENSORS:

y There are four extensors of the knee are collectively known as

quadriceps femoris muscle.

y The only portion of the quadriceps that crosses tow joints is the

rectus femoris, which originates on the inferior spine of the ilium.

y The muscles of the quadriceps femoris extend the knee.


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y The resultant pulls of the muslce fibres in relation to long axis of

femur to be 7-10 degrees medically and 3-5 degrees anteriorly.

y The pull of the Vastus lateralis alone was found to be 12-15 degrees

lateral to the long axis of the femur.

y The pull of the Vastus intermedius was parallel to the shaft of the

femur, making it the purist knee extensor of the group.

y In weight bearing, the quadriceps control knee flexion (rather thancreating extension) by acting eccentrically during activities.

y

The quadriceps then works concentrically in extension to return thebody to the erect posture.

y When the erect posture has been attained, activity of extensors

ceases.

y No knee extensor muslce activity is necessary in normal erect stancebecause the log is located anterior to the axis of flexion andextension at the knee joint.


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FUNCTIONAL RANGE OF MOVEMNET OF KNEE:

Normal gait requires:

67 degrees of flexion in the swing phase.

83 degrees of flexion for stair climbing.

90 degrees of flexion for descending stairs.

93 degrees of flexion in rising from a chair.


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INDICATIONS

Infection: Like cellulitis, abscess, delayedhematogenous seeding.

Trauma.

Long history of degenerative joint diseases.

Rheumatoid arthritis.

Osteoarthritis.

Systemic lupus erythematosus.

Disabling knee pain with functional impairment.

Arthritic involvement where conservative measuresincluding ambulatory aids, NSAIDS, are not useful.

After excision of malignant tumors.

Smoking.

Long-term steroid therapy.

Diabetes mellitus.

Hypoproteinemia.

Hypothyroidism.


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CLASSIFICATION

The total knee replacement can be classified into

a.)Uni-compartmental.

b.)Bi-compartmental.

c.)Tri-compartmental.

a.)Uni-compartmental:

f The articular surfaces of femur and tibia of either the

medial or the lateral compartment of the knee are replacedby implant.

f This type is indicated for disease pertaining to onecompartment only

f E.g.. Osteoarthritis.

b.)Bi-compartmental:

f The articular surface of tibia and femur or both medial and

lateral compartments of the knee joints is replaced by animplant.


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c.)Tri-compartmental:f The articular surface of the lower femur, upper tibia and

the patella are replaced by prosthesis.

f This arthoplasty is most commonly performed now a day.

f The process consists of tibial component, a metal femoralcomponent and high molecular weight polyethylene button

for the articular surface of the petella.

Classification:

Unconstrained.

Semi-constrained.

Fully constrained.

lUnconstrained:

Relies heavily on soft tissue integrity to provide joint

stability. It is rarely used.

lSemi-constrained:

Flexion contractures up to 45 degrees and angular

deformities up to 25 degrees can be corrected.

lFullyconstrained:

It is performed for severe instability and severe

deformity.


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CONTRAINDICATIONS

CONDITIONS OFCVS:

j Myocardial infarction

j Angina

j Hypertension

j Diabetes mellitus

jPeripheral vascular diseases

CONDITIONS ON RESPIRATORY SYSTEM:

j emphysema

j COPD

j Embolus /DVT

OTHERS:

j

Recent / current joint infection

j Septicemia of joint

j Neuropathic arthropathy

j Severe osteoporosis

j Non-functioning extensor mechanism

j

Obesity

j Age > 70 years

j Drug users (ethanol, tobacco )

j GI reflux disease.


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INVESTIGATIONS

1. LAB STUDIES:

* Hemoglobin percentage is low.

* Decreased WBC or normal.

* Increased lymphocytes.

* ESR raised.

2. X-RAY FINDINGS:

* Loss of joint space.

* Sclerosis.

* Subchondral cysts found.

* Osteophytes.

* Deformity and mal-alignment.

3. IMAGING STUDIES:

* Bone scan- shows increased uptake of technetium-99m.


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* MRI- it is the first choice to evaluate the

degenerative, rheumatic and traumatic joints

* CT scan: Very useful non-invasive procedure.

4. SYNOVIAL FLUID ANALYSIS:

* It shows non inflammatory picture in osteoarthritis.

* It is typically yellow, watery, and turbid due to highW.B.C. and has a low sugar content.


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SURGICAL

PROCEDURES

INTRODUCTION


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Surgical repair of soft tissue around the joint is difficulty.

The design of the successful total knee replacement have been

remarkably similar with a metal condylar compartment with patellarslange and a metal backed high-density polyethylene (HDP) Tibial

surface with a central knee for stability.

In oldendays cemented devices has been used, replaced by theuncemented devices presently.

The sepsis rate with the surgery is reduced to 1% due to wear ofpolyethylene of patello-femoral joint

TOTAL KNEE REPLACEMENT:

y A total knee replacement resurfaces the knee joint by removing the

diseased bone and cartilage.

y This includes the lower end of the thighbone (femur), the upper end of

the shinbone (tibia), and the backside of the kneecap (patella).

y These surfaces are replaced with a metal and plastic implant, whichmimics natural knee motion and function.

y Total knee replacement can help put an end to arthritic pain in yourknee and enable you to resume a functional and active lifestyle.


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Procedure:

-

Skin incision:

y Longitudinal midline or medial para-patellar skin incision.

y In revision surgery, use the most lateral incision usable, as thesuperficial blood supply comes mainly from the medial side of the

knee.

- Deep dissection:

1.)

Medial parapatellar.

2.)Subvastus.

3.)Lateral parapatellar approach.

4.)Quadriceps turndown.

5.)Tibial tubercle osteotomy.

1.) Medial parapatellar

2.) Subvastus:

y

Vastus medialis reflected laterally.

y There is less interference with the extensor mechanism, butdifficult to obtain a good view in the obese.

3.) Lateral parapatellar approach:


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y Sometimes used in valgus knee.

yFor difficult primary/revision knee replacement, to protect theTibial tubercle from avulsing on lateral rotation of the patella.

4.) Quadriceps turndown:

y Standard medial parapatellar approach with additional limb

extending laterally.

yBeware the lateral superior genicular artery.

y Can be converted into an Y on closure if there has been

quadriceps contraction secondary to knee stiffness.

y Stitch in the position where gravity alone will allow flexion to 90

degrees.

y Post operatively active extension should be delayed and a splint

used for walking for 2-3 months.

5.) Tibial tubercle osteotomy:

y 3-6cm length.

y Tibial tuberosity still attached to lateral musculature.

y Fix back with screws.

y Commonly a tourniquet is applied the leg is exsanguinated and

the tourniquet tightened for a time period.


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y When the knee in flexion the surgical approach is on the wh ole

by anterior skin incision followed by medial parapatellar incisionthrough quadriceps expansion.

y Cut the tibia perpendicular to the mechanical axis of the limb

with a posterior slope of 0-5 degrees depending on the design ofprosthesis.

y Cut the distal cut on the femur at a valgus angle of 5-7 degrees

from the anatomical axis of the femur.

y Use an intra-Medullary alignment jig if possible. The amount ofbone taken off should be equivalent to the thickness of the

femoral component.

y Size the femoral component to avoid notching of the femur.

y To make the flexion gap rectangular, place the femoral cuttingblock on the femur so there is some external rotation of the block

of approximately 3 degrees in relation to the posterior condyles.

y This is because the tibial cut has been made perpendicular to the

mechanical axis of the leg not the anatomical axis of the tibia,

which is 3 degrees from the mechanical axis.

y The femoral component is held in place by two short pegs

cemented in to each condyle and the tibial component by a largesingle peg in to the tibia.

y Flexion gap is assessed with the knee in 90 degrees of flexion.

y Extension gap is assessed with the knee in full extension.

y The flexion gap and extension gaps should be rectangular and

roughly equal to each other. Assess using laminar spreaders orspacers or trial prostheses.

y Always check flexion gap and adjust extension gap.


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PROGNOSIS:

y 94% of patients survival for 11 years by total condylarprosthesis.

COMPLICATIONS:

It willbe divided as:

1.)Intra-operative.

2.)Post-operative divided as:

* Short term complication

* Long term complications.

1.)Intra-operative:a.)Neuro vascular damage.

b.)Arterial damage rare< .05%.

c.)Peroneal damage- usually in correcting of valgus

deformity.

d.)Fat embolism

2.)Post-operative: short term complications.Is up to 8 weeks.

a.)Deep vein thrombosis.

b.)Pulmonary embolism.


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c.)Chest infection.

d.)Wound infection.

e.)Heart dysfunction.

f.)Bleeding.

g.)Deep infection.

h.)Neuropraxia.

i.) Haematoma.

Long term complications: -

isup to 18 months.

a.)Stiffness. - Due to inflammatory exudate builds atrest.

b.)Infections. - Due to open surgery.

c.)Anaesthetic risk. - Due to general anaesthetic.

d.)Deep vein thrombosis. - Due to damage to the bloodvessels during surgery.

e.)Anemia.- blood loss during/post surgery.

f.)Swollen ankle.- due to ineffective muscle pump.

g.)Back pain- due to unequal leg length.

h.)Neck pain- due to neck being held in an extended

position during the incubation.


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lAny intra-articular steroid injection in to the joint.

Family history:

lAbout general family health.

lPrevious occurrence in family.

lBackground family support and financial ability.

Personal history:

lSmoking.

lAlcoholic consumption.

lDiet and sexual life.

Social and occupational history:

lMarital status.

lArea of living.

lHobbies of patient.

OBJECTIVE:

History of pain:

Measured by visual analog scale.

a) Site of pain:

y Localized/diffused.

y Ask the patient to denote maximum area of pain.


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b) Time and mode of onset:

y Triggered factor of pain onset. Sudden/insidious.

c) Severity of pain: Mild, moderate, severe

d)Nature of pain:

Aching.

Stabbing.

Burning.

Throbbing.

e) Progression of pain: worse or decreased.

f) Radiating of pain: Direction and extent.

g)Aggravating factors:

y By joint movement.

y Walking and standing.

y Body posture etc

h) Relieving factors are analgesics, fomentations etc.

History of swelling:

i.) The area and extent of effusion.

ii.) Symptoms all with lump- pain pressure symptoms, vascularsymptoms.

iii.) Progression of lump joint- is getting bigger/smaller.


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ON EXAMINATION:

Built of patient.

Presence of anemia.

Presence of edema.

Fever.

Joint deformity.

Range of motion: - Accurate measurements of the active and

passive ROM at the knee are recorded.

Patellar mobility checked and graded.

Ligament stability around the knee is evaluated.

Strength and endurance:

y Of quadriceps.

y Hamstrings.

y Glutei.

y Crutch muscles.

The quality of quadriceps contractions needs to be asses sed.

Atrophy: - Checked for muscle atrophy. Mainly quadriceps.

Gait pattern: -

y Check for status of ambulation.

y Check for complete gait analysis.


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PRE-OPERATIVE PHYSIOTHERAPY

TREATMENT

Explain to the patient about the surgery.

Biomechanics of the movements at the knee should be explained on

the normal knee.

Explain about importance of regaining early range of motion at theknee.

Educate the patient on the measures taken for prevent ion of

lEdema.

lDeep vein thrombosis.

lChest complications.

Training of isometric exercises for quadriceps, hamstrings, andglutei.

Relaxed free movements of knee joint should be taught to the patient

in sitting, standing, lying.

Assisted active and resistive exercises should be taught on sound

limb.

Techniques of self-assisted mobilization and strengthening areexplained.


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REASSURENCE: -

It places a major role in the recovery following surgery.

Uses:

y To prevent of thrombosis, by maintenance of

circulation of good limbs.

y To prevention of chest complications.

y

To preserve mobility of other joints.

y To improve mobility of effected joint.

y Educate the patient to identify bedsores, DVT,joint tightness.


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POST OPERATIVE PHYSIOTHERAPY

ASSESSMENT

ON OBSERVATION:

General observation:

y Check for conscious level.

y Physical condition.

y Posture of the patient.

y Built of the patient.

Local observation: -

y Extent of swelling.

y Skin texture- Shiny/wrinkled

y Limitation of function.

y Incision type.

On palpation:

y Warmth.

y Tenderness.

y Edema- Pitting/non-pitting/extending distally or

proximally.

y Pulses- Femoral/popliteal artery/dorsalispedisartery/tibialis posterior artery

y Scar- Healed/unhealed.


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On examination:

y Check for effected limb length.

y Range of motion of knee joint-

y Soft tissue endfeel.

y Capsular endfeel.

y Bony endfeel.

y Check for pain free limit.

y Check for voluntary muscular control.

y Check for muscular strength-

y Muscle girth.

y Muscle tone.

y Check for deformity- Valgus/varus/genurecurvatum.

Respiratory assessment:

y Check for tidal volume.

y Breathing pattern.

y Type of respiration.

Assess the psychological status of patient.

Assess the diet and medications.


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POST-OPERATIVE PHYSIOTHERAPY

MANAGEMENT

PROBLEM LIST:

i.) Pain at knee joint.

ii.) Stiffness of the knee joint.

iii.) Decreased muscle power of quadriceps and hamstrings.

iv.) Decreased movements of knee joint.

v.) Deep vein thrombosis.

vi.) Swollen ankle.

vii.) Back pain.

viii.) Patellar movements decrease.

ix.) Decreased muscle bulk of quadriceps.

x.) Shortening of quadriceps muscle.

xi.) Deformities like varus or valgum.

xii.) Contractures of hamstrings.

xiii.) Decreased muscle tone of quadriceps.


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AIMS:

i. To decrease pain of knee joint.

ii. To decrease the stiffness of the knee joint.

iii. To increase muscle power of the quadriceps and hamstrings.

iv. To increase the movements of the knee joint.

v. To prevent the deep vein thrombosis.

vi. To increase the patellar movements.

vii.To increase the muscle bulk of quadriceps.

viii. To prevent the deformities

ix. To prevent Contractures.

x. To increase the muscle tone of quadriceps.

MEANS:

Day 1.

1.)Chest Physiotherapy.

2.)Vigorous toe and ankle movements.

3.)Static glutei and quadriceps by pressing the pillow below the heel.

4.)Gentle isometrics to quadriceps- it should be progressed to rhythmicspeedy quadriceps contractions and relaxation which will promotepatellar excursion and reduce edema.

5.)Maintain the limb in extension (by resting the heel on a pillow).


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Day 2-3

1.)Transfers in bed.

2.)Rapid isometrics to quadriceps, hamstrings, glutei and hip abductors

(Speedy and with 10 second hold).

3.)Assisted SLR- could be initiated with simultaneous isometrics to

quadriceps and ankle in maximum dorsiflexion.

4.)Stand and ambulate with POP on and walker.

Day-4-5-6

1.)Transfers in chair.

2.)Self-assisted passive knee flexion.

a.)Heel drag in supine.

b.)Bed side sitting, relaxed knee movements with the

help of sound leg (in unilateral TKR).

c.)Sitting with feet planted on the ground, lift and pushforward by raising trunk on arms.

3.)CPM-5-10 degrees daily (1 cycle per minute).

- Range of knee flexion MUST NOT EXCEED 40 degreesbecause transcutaneous O2 tension of the skin near the

incision decreases significantly after 40 degrees of flexion.

4.)Begin active or active assisted exercise, if the wound is clean anddry.

5.)Bed side active knee flexion-extension (self-assisted, if necessary)


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6.)Ambulation without POP (can do three SLR without POP).

7.)Work-up towards 90 degrees flexion by 10-14 days.

8.)Hamstrings strengthening.

9.)Assisted step and stairs.

Second week:

y SLR should be made intensive by slow speed SLRS with self-generated

tension in the quadriceps without relaxation in between SLRS.

y Intensify relaxed passive and assisted active knee flexion exercises. By

this time the range of knee flexion should reach 90o

or close to it.

y At the same time independent SLR without reflex inhibition of

quadriceps should be achieved.

y Once three independent SLRS against gravity in supine are achieved,ambulation without immobilizes can be begun.

y Weight transfers and Partial weight bearing on the operated limb maybe begun on crutches.

y Assisted step and stairs.

3-6 weeks

y Work up to achieve knee flexion close to 110 -115 degrees.

y Single crutch walking and well-assisted stir activities should be

introduced.

y Sessions on ped-o-cycle or even stationary bicycle could be begun.

y Gait training with emphasis on free knee swinging be started with a

cane and progressed from Partial weight bearing to total weightbearing.


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y Hydrotherapy or pool exercises are ideal at this stage if the surgical

wound has healed.

y Quadriceps dips and step and stairs in normal pattern could be initiatedwith assistance.

6 weeks onwards

y The patients gait with cane should be assessed for any deviation. Alsoensure that both the tibio-femoral compartments of the prosthesis are

loaded evenly and not like a normal knee joint where the loaded evenlyand like a normal knee joint where the loading is predominantly medial.

y The specific exercise for the still persisting deficiencies to be planned

and taught.

y Guided assistance may be provided for the higher levels of functional

and ambulatory activities.

y Cane should be discarded by assuring normal gait pattern and the

degree of stress during job requirements, by 12 weeks.


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4- STRAIGHT LEG RAISE:

While lying flat on your back with your uninvolved leg bent and your foot flat on the

surface, tighten your thigh and lift your involved leg. Keep your knee straight. Only lift

to the height of the uninvolved knee. Repeat with other leg.

5- SIDE LYING ABDUCTION:

While lying flat on your uninvolved side. Bend your uninvolved leg forward.Raise involved leg about five inches and then lower to starting position.

Do Not allow your toes or knee to turn upward. Repeat with other leg.

6- SITTING KNEE EXTENSION:

While sitting in a chair, straighten your involved knee as far as you can.Hold for 5 seconds.Repeat with other leg.


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DOS:

- Stationary bicycling.

- Swimming.

- Walking.

- Self-isometric exercises for quadriceps.

- Strengthening exercise for quadriceps, hamstrings.

- Relaxed free movements of knee joint.

- Hiking.

- Low-resistance weight lifting.

- If pain is there advise to go for hot water fomentation orIce application.

Donts

- Avoid sports.

- High impact aerobics.

- Jogging.

- Power lifting.

- Rock climbing.

- Hang gliding.

- Parachuting.


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Review of literature

For the study to be under taken the review of previous

existing literature has to be thoroughly analyses to support thestudy so many literatures are there to support this study

A study done by Harvey LA, Brosseau L, Herbert RD.

Twenty randomized controlled trials of 1335 participants met the inclusioncriteria. There is high-quality

evidence that continuous passive motion increases passive knee flexion

range of motion (mean difference 2 degrees, 95% CI 0to 5) and active knee flexion ra nge of motion (mean difference 3 degrees,95% CI 0 to 6). These effects are too small to beclinically worthwhile. There is low-quality evidence that continuous

passive motion has no effect on length of hospital stay(mean difference -0.3 days; 95% CI -0.9 to 0.2) but reduces the need for

manipulation under anesthesia (relative risk 0.15;95% CI 0.03 to 0.70).AUTHORS' CONCLUSIONS: The effects of continuous passive motionon knee range of motion are too small to justify its

A study done by Ahmed AR, Abd-Elkader SM, Al-Obathani KS.

Effect of a 6-week rehabilitation program on gait parameters afterTotal knee arthroplasty.

CONCLUSION: A 6-week postoperative exercise program is not a longenough time-period to restore walking abilities to their

Pre-surgery values in patients undergoing TKA. A longer period ofrehabilitation is needed to improve the quality of the patient's

gait.

A review done by Saleh KJ, Lee LW, Gandhi R, Ingersoll CD,

Mahomed NN, Sheibani-Rad

Quadriceps strength in relation to total knee arthroplasty Outcomes.


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After total knee arthroplasty, quadriceps femoris muscle strength is an

important determinant of physical function. Quadriceps weakness is often

present in the osteoarthritic limb and worsens after total knee arthroplasty.Although some quadriceps strength is regained, it may take more than 2

years to achieve preoperative levels .

A review done by Laufer Y, Snyder-Mackler L.

Response of male and female subjects after total knee arthroplasty to

repeated neuromuscular electrical stimulation of the quadriceps femorismuscle.

CONCLUSIONS: After total knee arthroplasty, most elderly subjects cantolerate neuromuscular electrical stimulation at

current intensities sufficient to elicit quadriceps femoris musclecontractions within the therapeutic range recommended for

muscle strengthening. Although male subjects can tolerate stronger currentintensities, similar %MVIC is activated in femaleand male subjects with impaired muscle function, indicating a similar

potential for treatment ef fectiveness.


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AIMS AND OBJECTIVES OF STUDY

The major aim of the study is to get the full range of motion

and pain free knee.

The object of the study is to employ the physiotherapeutic modalities toreduce pain.

TYPE & DESIGN OF STUDY:-Randomized control study.

PLACE OF STUDY:-SIMS College of Physiotherapy,

OUT PATIENT DEPT;Guntur.

NUMBER OF SUBJECTS:- 20 Subjects were taken for thestudy.

PARAMETERS:-RANGE OF MOTION, STRENGTH.Tools: - For ROM GONIOMETER.

MATERIALS:-y Pillows.

y Couch.

y Goniometer.


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Inclusion criteria:

Subjects were selected for the study if they fulfill the

following criteria.

y Those who are willing to participate in the study and willing

to take treatment for 2 months.

y Patient aged below 45-60 years of age.

y Post operative knee joint stiffness.

y Patients with decreased muscle strength.

Exclusion Criteria:

y Subjects sufferings with infective condition of elbow, tumors,

complaints around the knee.

y Subjects with clinical disorders.

y Subjects with impaired circulation to the lower extremities.

y Subjects receiving analgesics preceding 3 months.


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Methodology:

In this study I want to know the effect of continuous

passive movements machine and various exercises of the knee jointin relation to the post operative management.

I have selected 20 subjects; selection is purely based oninclusion and exclusion criteria.

Among the 20 subjects, 16 are males and 4 are females

and I have given 10 forCPM along with exercises and 10 for onlyexercises for 6 weeks.

Duration of Treatment:

y Mobilization excs are done for 20 minutes in a day for 5 days

a week which is continued for 6 weeks.

y Stretching, strengthening, free excs are also taught to the

patient and made to do exercises at home 3 sets a day.

y Before and after the treatment the pain and range of motion

have been assessed by using VAS Scale and GONIOMETRY

and results have been mentioned below.


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Result:

1. strength

Tab : 1 Tab:2

Range of motion:

B)Subjects

BeforeTreatment

AfterTreatment

1 8 5

2 7 5

3 9 6

4 9 6

5 6 4

6 8 5

7 7 4

8 6 4

9 8 5

10 9 6

Total 77 50

Mean 7.7% 5%

A )

subjects

Before

Treatment

After

treatment

1 8 4

2 7 4

3 9 3

4 9 2

5 6 3

6 8 4

7 7 2

8 6 3

9 8 3

10 9 4

Total : 77 32

Mean :

7.7%

3.2%


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A)Subjects Before

Treatment

After

Treatment

1 70 110

2 60 100

3 75 105

4 80 110

5 70 115

6 50 110

7 60 110

8 85 115

9 80 120

10 70 115

Total 700 1100

Mean

70%

110%

Tab 3: Tab 4:

B)Subjects

BeforeTreatment

AfterTreatment

1 70 100

2 60 90

3 75 100

4 80 110

5 70 110

6 50 90

7 60 105

8 85 115

9 80 120

10 70 110

Total 700 950

Mean 70% 95%


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0

20

40

60

80

100

120

140

ROM-CASE1 MUSCLE

STRENGTH CASE-1

ROMCASE 2 M/S STRENGTH

CASE2

BEFORE RX

AFTER RX

0

20

40

60

80

100

120

140

ROM CASE 1 M/S

STRENGTHCASE 1

ROM CASE 1 M/S STRENGTH

CASE 2

BEFORE RX

AFTER RX

The above graphs show strength and range of motions before andafter treatment.


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CASE-1

Name : SekharKumar.

Age : 56 Years old.

Sex : Male.

Occupation : Businessman.

Address : Auto nagar, Vijayawada.

PRE-OPERATIVE ASSESSMENT:

Chief complaints:

Severe pain in right knee and stiffness of the joint.

Past medical history:

Patient is a known osteoarthritic since 3 years and wasunder regular medical treatment. - NSAIDS,Analgesics.

No history of trauma.

No history of previous surgeries.

Patient was known diabetic and hypertensive with

regular treatment.

Present medical history:

The patient was admitted in GGH, VJA before four

days and the date for surgery is given by surgeon forthe total knee replacement.


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Pain history:

Site of pain: localized around the knee.

Time and mode of onset: Gradual and severe.

Progression of pain: Worse.

Aggravating factors: Standing, sitting, climbing stairs.

Relieving factors: Rest, hot packs, NSAIDS.

History of swelling:

Swelling is present.

Progression of lump is getting bigger gradually.

ON EXAMINATION:

Range Of Motion-

Decreased.

Flexion-100o,

Extension-120-5o

Decreased patellar movements.

Muscle power:

Decreased of quadriceps and hamstrings.

Muscle girth:

Decreased.


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Deformity:

Genu varum is noted.

Gait:Abnormal due to pain.

PRE-OPERATIVE PHYSIOTHERAPY TREATMENT:

AIMS:

To educate the patient about the surgery.

To prevent the postoperative complications.

To have a controlled pattern of breathing before and after surgery.

To train the patient about postoperative exercises and the eff ects of those.

MEANS:

Explanation is given to the patient about surgery

Breathing exercises are taught.

Relaxed free movements of knee joint are taught to the patient in sitting,standing, lying.

Assisted active exercises and resisted exercises are taught on sound limb.


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POST OPERATIVE ASSESSMENT

OBJECTIVE ASSESSMENT: WITH (PLASTER OF PARIS)

As the patient is in PlasterOf Paris therapist have check the other joints.

GENERALOBSERVATION:

Patient is coherent.

Physically normal except the treated part.

Built- Endomorph.

Posture- Patient is lying position as applied POP cast to the

right lower limb and was rested on a pillow placed from kneeto ankle.

Attitude of limb: Laterally rotated.

LOCALOBSERVATION:

Swelling- is present at the right ankle.

Skin- No skin changes observed distally.

ON EXAMINATION:

Range Of Motion - All other joints normal that is right hip

and ankle, MTP and IT joints


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Muscle Strength- Examine the upper limbs.

Shoulder- Flexors - Normal.

Extensors -3+

Abductors. -4+

Adductors. -Normal

Rotators -3+

Elbow- Flexors -Normal

Extensors. -4+

Wrist and

Fingers-Flexors-4+

Extensors. -Normal.

Limb length- affected limb-85 cms,Unaffected limb-85 cms.

Breathing pattern: Normal.

ON PALPATION:

Normal pulse of dorsalispedis artery.

Tenderness on the other areas are not elicited.


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OBJECTIVE ASSESSMENT (WITH OUT PLASTER OF PARIS):

ONOBSERVATION:

Swelling. - Mild swelling or edema in and around rightknee.

Skin texture- greasy and wrinkled as POP is removed.

Incision type- Medial parapetellar.

Posture- Normal.

Breathing pattern- Normal.

ON PALPATION:

Warmth- Localized.

Tenderness- Present.

Edema- Mild,

Scar- Unhealed.

ON EXAMINATION:

Range Of Motion - Decreased due to pain that is activeflexion and extension.

Right Knee Normal range

Flexion- 45o. 120

o

Extension-5 o 120-0 o

Muscle power- Decreased

Quadriceps- 3


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Hamstrings- 2+

Muscle girth- Decreased quadriceps of right knee.

Right knee Sound limb

21 inches 26 inches

Limb length- affected-85 cmsUnafected-85 cms

Deformity: No deformity is noted.

Activity of daily living (ADLs)- Unable to walk, sit.

Decreased activities of Toileting.

PROBLEM LIST:

Pain- At medial part of right knee.

Swelling.

Decreased movements of right knee flexion and extension

Decreased muscle power of quadriceps

Scar formation.

Decreased ADLs.

AIMS

To regulate the normal respiration.

To decrease pain.

To decrease swelling.


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To increase movements of right knee.

To increase the power of quadriceps and hamstrings of rightknee.

To mobilize the scar.

To promote early ambulation.

To improve his ADLs.

MEANS

Day-1-2-3

Breathing exercises.

Ankle and foot exercises.

Isometric exercises for gluteus and quadriceps to right kneeare taught.

Made the patient to turn frequently in bed.

Assisted SLRs are taught.

Made the patient to stand and ambulate with POP on and

walker frames.

Day-4-10

Gentle patellar mobilization is done.

Self assisted passive knee flexion:

a) Heel drag in supine.

b) Bed side sitting, relaxed knee movements withthe help of sound limb.

c) Sitting with feet planted on the ground, lift andpush forward by raising trunk on arms.


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Active assisted exercises are performed.

Resisted exercises for hamstrings.

Knee is flexed up to 90o.

Made him to climb few steps.

Ambulation is done by the support of frame without POP.

Day-11-3weeks

All the above exercises are continued.

4th

-6th

week:

Active free exercises for right quadriceps.

Static bicycle for five minutes in 3-4 times per day.

Active knee flexion is done upto 115o

Made him to walk with stick.

Quadriceps dips and steps up.

After-6 weeks

Gait with stick is progressed.

Stick is discarded by 11th

week.


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HOME PROGRAM:

Advice to do

The free exercises of right knee joint.

Sitting- flexion and extension.

Standing- flexion and extension.

Lying- right knee flexion and extension.

Active assisted exercises

Active resisted exercises.

Cycling

Early morning walk.


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CASE-2

Name : Chandra Mouli

Age : 52 Years

Sex : Male.

Occupation : L.I.C. Development officer.

Address : Mangalagiri.

Chief complaints :

He is suffering from left knee joint pain since 2months.

He is unable to walk with out walking aid-havinglimp.

Duration : 2 Months.

On set : Gradually.

Present medical history :

Patient is used to takeAnalgesicsNSAIDS

Steroid therapy

Past medical history :

The patient is known left knee bone tumor and

was under regular treatment.

Positive history of surgery- Patient was

undergone surgical reconstruction of left knee 2months back.


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OBJECTIVE ASSESSMENT

ONOBSERVATION:

Built- mesomorph.

Swelling- Present.

Skin texture- normal

Posture- In standing position patient bend towards the

opposite side to compensate limb length disparity.

Gait- Patient bending right side.

Deformity- Flexion deformity of left knee.

Scar- Healed.

ON PALPATION:

Warmth- Localized.

Tenderness- Present

ON EXAMINATION:

Range Of Motion: Decreased

Left knee. Normal range

Flexion-55o

120o

Extension-5o

120-0o

Other limbs are normal that is shoulder, trunk, hip, and

ankle.


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PROBLEM LIST:

Pain at lateral and superior parts of left knee joint.

Decreased joint Range Of Motion of flexion andextension

Decreased muscle power of left knee quadriceps and

hamstrings.

Joint stiffness.

Decreased muscle girth of quadriceps.

Contractures of hamstrings.

Decreased ADLs

AIMS

To decrease pain.

To increased joint ROM.

To increase the muscle power.

To decrease the joint stiffness.

To improve the muscle girth.

Prevent Contractures.

To improve the ADLs


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MEANS

To decrease pain:

RICE (Rest, Ice, Compression and Elevation)

Rest

Proper positioning with adequate support

Wax bath is applied.

To improve joint ROM

Passive movements are done.

Assisted exercises.

Resisted exercises by using quadriceps table.

Patellar movements are performed.

Massage- Kneading techniques are done around

the left knee joint.

To improve muscle power-

Rapid isometric exercises for quadriceps andhamstrings.

Assisted exercises:

Knee flexors:

Assisted exercisesare performed- in side lying the leg is supported

in the horizontal position with the hip joint flexed, the thigh is, thenfixed and knee flexion is assisted manually.


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To preventC

ontractures:

Stretching to left knee quadriceps and

hamstrings.

Hot packs.

Ice application.

Massage.

To improve ADLs:

Free exercises are teached.

Active mobilization of left knee joint.

Progressive resisted exercises are teached.

HOME PROGRAM:

Advise to do self-free exercises. - Knee flexion and extension

in sitting, standing, lying, side lying, prone lying.

Active assisted exercises.

Active resisted exercises.

Cycling.

Climbing stairs.


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CONCLUSION

It has been interpreted and concluded through periodical evaluationand follow up assessment. The patient who has undergone `total knee

arthroplasty was given intensive physiotherapy.

The physiotherapy specifically based on the rehabilitation protocol,which is included in this cumulative work. The sessional physiotherapy

was given with natural forces and remedial exercises.

The improvement observed initially was the basement for thepatients cooperation. The progression was made right from recumbent

position till stance phase and gait pattern gradually.

Though sub-normality was observed in the earlier stages of gait

analysis- Phase by phase gait pattern and transference of body weight were

taught with concise explanation and demonstration there by patient isfunctionally independent.

I conclude this project work with pleasure and it is all about mental

contentmentasafinalyearstudentofphysiotherapy.


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BIBLIOGRAPHY

1. CLINICALANATOMY FOR MEDICAL - RICHARD .S.NELL

STUDENTS 5TH

EDITION

2. HUMANANATOMY - B.D. CHAURASIA3

RDEDITION

3. JOINT STRUCTURE AND FUNCTION - PAMELA. K.

CYNTHIACNORKIN

4. CLINICALASSESSMENT AND - C REXEXAMINATIONONORTHOPAEDICS 1

STEDITION

5. ORTHOPEDIC PHYSICALASSESSMENT - DAVID J. MAGEE3

RDEDITION

6. ESSENTIALOF ORTHOPEDICS - JAYANTH JOSHIAN

DA

PPL

IED PHYSIO

THERA

PY PRAKA

SHKO

TWAL

7. TIDYS PHYSIOTHERAPY - ANN THOMSONALISON SKINNERJOAN PIERCY

12TH

EDITION

8. THE LOWER EXTREMITY AND SPINE - JAMES A.NICHOLAS, ELLIOTB. HERSH MAN

2ND

EDITION

9. TEXT BOOKOF ORTHOPAEDIC SURGERY- MERCER

10.OUT LINE OF ORTHOPAEDICS - JOHNCRAWFORD

ADAMS10

THEDITION


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Documents

A Project on Knee arthoplasty