Post Operative Management- TKR

7/31/2019 Post Operative Management- TKR

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Post operative management-TKR

Dr.S.Mageswaran. M.S.Ortho

Assistant professorTirunelveli medical college



Introduction Post operative management plays a

vital role to restore the knee mobility

and strength and a gradual return toeveryday activities



Phases of post op protocol

Phase 1 - Initial Phase - First week

Phase 2 - Motion Phase - 1-6 weeks

Phase 3 - Intermediate Phase - 7-12 weeks

Phase 4 - Advanced Phase - 13-16 weeks



Phase 1- First week Goals

To decrease the swelling

Enhance muscle strenth and control

Indepentent transfer from bed

Independent ambulance with appropriate

assistant device Attain full extention (0°) and 90°of flexion



Phase-1

Day of surgery Asses the extent of recovery from

anaesthesia

Post operative protocol starts 6 hoursafter discontinuation of anaestheticmedication



Phase-1

Day of surgery cont… Post op patient Positioning

A towel roll placed under the ankle

Nothing should be placed behind theoperative knee joint

A troconteric roll should be used to

maintain netural hip rotation and therebypromote knee extention



Phase-1

Day of surgery cont…

CPM 0-90 degree in the post op room inminimum of 4 hrs

Ice for 20 min every 2 hrs

Early post op exercise



Phase-1

Early post op exercise Patient can begin exercises in the

recovery room shortly after surgery.

Quadriceps Sets

Straight Leg Raises

Ankle Pumps

These exercises actually diminishes thepostoperative pain.



Quadriceps Sets Tighten the thigh muscle. Try to straighten

the knee. Hold for 5 to 10 seconds.

Repeat this exercise approximately 10 timesduring a two minute period, rest one minuteand repeat. Continue until the thigh feelsfatigued



Straight Leg Raises

Tighten the thigh muscle with theknee fully straightened on the

bed, as with the Quad set. Lift theleg several inches. Hold for five to10 seconds. Slowly lower.

Repeat until the thigh feelsfatigued.



Ankle Pumps

Move the foot up and down

rhythmically by contracting the calf and shin muscles.

Perform this exercise periodically fortwo to three minutes, two or threetimes an hour in the recovery room.



Phase-1

Post op day-1 Use CPM 3 times per day for 2 hrs at a

time

Increase CPM approximately 10°daily.

Continue CPM until patient achieves 90°of active knee flexion.

Ice involved knee for 15 minutes forminimum of 3 times per day



Phase-1

Post op day-1 cont… Review and perform all bedside

exercises

Sit at the edge of bed with necessaryassistance.

Ambulate with standard walker 15’ with

moderate assistance.

Sit in a chair for 15 minutes.



Phase-1

Post op day-2 Perform bed exercises independently 5

times per day.

Perform bed mobility and transfers withminimum assistance.

Ambulate with standard walker 50’ with

contact guarding.



Phase-1

Post op day-2 cont… Ambulate to the bathroom

Sit in a chair for 30 minutes twice perday, in addition to all meals.

Actively move knee 0-70°.

Sitting supported knee bends andsitting unsupported knee bends started.



Phase-1

Post op day-3 Perform bed mobility and transfers with contact

guarding.

Ambulate with standard walker 75’ with supervision

Ambulate with WBQC 75’ with supervision

Sit in a chair for most of the day, including all meals.Limit sitting to 45 minutes in a single session.




Phase-1 Post op day-4

Perform bed mobility and transfersindependently.

Ambulate with WBQC 100’ with distantsupervision.

Negotiate 4-8 steps with necessaryassistance.

Perform HEP with assistance.



Phase-1 Post op day-5

Ambulate with WBQC 100’ independently.

Negotiate 4-8 steps with WBQC safely.

Perform HEP independently.


Discharge from the hospital to home



Criteria for progression to thenext phase

Independent SLR

Active knee range of motion (AROM)

0-90°

Minimal pain and inflammation

Independent transfers

Ambulation at least 100 feet withappropriate assistive device



Phase II Motion Phase (week 1-6)

Goals:

Progress from WBQC to straight cane. Improve involved lower extremity strength

and proprioception.

Maximize function in the homeenvironment.

Attain 0-110° active knee motion.



Phase II Weeks 1-4

Progress ambulation distance with WBQC.

AA/A/PROM, stretching for flexion (>90

degrees) and extension Begin stationary bicycle with supervision for

5-10 minutes.

Stair Climbing and Descending Neuromuscular electrical stimulation (NMES)

for quads if poor quad contraction



Stair Climbing and Descending

Go only one step at a time

Always lead up the stairs with your good knee anddown the stairs with your operated knee.

Remember, "up with the good" and "down with thebad."

Do not try to climb steps higher than the standardheight (7 inches)

Always use a handrail for balance. Stair climbing is an excellent strengthening and

endurance activity.



Phase II WEEKS 4-6

Practice with straight cane indoors.

Increase stationary bicycle endurance

to 10-12 minutes, twice per day.

Attempt unilateral stance on theinvolved leg and side stepping.

Incorporate gentle semi-squats

Attain AROM 0-110°



Criteria for progression to the next phase:

AROM 0-110’

Good voluntary quadriceps control

Independent ambulation 800 feet,without assistive device, deviations orantalgia

Minimal pain and inflammation



Phase IIIIntermediate phase (week 7-12)

Goals:

ROM to 0-115°

Good patella femoral mobility

Good strength all lower extremitymusculature.

Return to most functional activities andbegin light recreational activities



Phase III

Therapeutic Exercises:

Continue exercises listed in Phase II withprogression including resistance andrepetitions.

open/closed chain exercises Initiate endurance program Initiate and progress age-appropriate balance

and proprioception exercises. Discontinue NMES of quads when appropriate

quad activity is present.



Criteria for progression to nextphase

AROM 0-115° without pain, or

plateaued AROM based on preoperativeROM status.

Good muscular performance of all lower

extremity musculature.

Minimal to no pain or swelling



Phase IV Advanced strengthening and higher levelfunction stage (week 12-16)

Goals:

Return to appropriate recreational sports /

activities as indicated

Enhance strength, endurance and

proprioception as needed for activities of daily living and recreational activities



Phase IV

Therapeutic Exercises

Continue previous exercises with progression

of resistance and repetitions. Increased duration of endurance activities

Initiate return to specific recreational activity:

golf, doubles tennis, progressive walking orbiking program.



Criteria for Discharge fromPhysical Therapy

Non- antalgic, independent gait Independent step over step stair climbing Pain-free AROM Good muscular performance of all lower

extremity musculature.

Normal, age appropriate balance andproprioception. Patient is independent with home exercise

program.



Thank you

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Post Operative Management- TKR