Rehabilitation Guidelines for patients undergoing · Web viewRehabilitation Guidelines for patients undergoing Total Knee Replacement (TKR), Patellofemoral Knee Replacement (PKR) or

Rehabilitation Guidelines for patients undergoing Total Knee

Replacement (TKR), Patellofemoral Knee Replacement (PKR)

or Unicondylar Knee Replacement (UKR)

Date Approved 25/09/2014

Ratifying Body Joint Academic Committee

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Author Helen Nafis

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Rehabilitation Guidelines for patients undergoing Total Knee Replacement (TKR), Patellofemoral Knee Replacement (PKR) or Unicondylar Knee Replacement (UKR) |

Page 1Date Approved 25/09/2014

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Subject List any subject your guideline fits into (see the Subjects Excel document under ‘Policies’ on Forms and Templates for list of options). Please replace all this text.

Review Date 1st May 2017

Keywords and Phrases Rehabilitation, total knee replacement , patellofemoral knee replacement, unicondylar knee replacement, physiotherapy, knee surgery, complications, outcomes, milestones, function, treatment, exercise, pain relief, restrictions, limitations, sport, fitness, postural awareness, pain education, mobility, goals, precautions, compliance, knee pain, leg pain

External References e.g. NHSLA

Consultation Group/Approving Bodies

RNOH Knee surgeons

Readership Clinical staff only

Choose an item.CQC Outcomes

Outcome 1: Respecting and involving people who use services

Outcome 4: Care and welfare of people who use services

Outcome 6: Cooperating with other providers

Outcome16: Assessing and monitoring the quality of service provision

NHSLA General Standards 4.1 Patient information & consent

4.2 Patient information

4.4 Screening Procedures

4.7 Physical assessment & examination of patients

4.14 Transfer of patients

4.15 Discharge of patients

5.6 Analysis

5.7 Improvement



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http://grapevine/docs/Forms%20and%20Templates%202/Subjects.xlsx

5.8 Best practice - NICE



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Table of Contents

1. Introductions and aims of guideline........................................................................3

1.1 Sub heading 2..................................................................................................3

2. Definitions...............................................................................................................3

2.1 Sub heading 2..................................................................................................3

3. Duties and Responsibilities.....................................................................................4

3.1 Sub heading 2..................................................................................................4

4. Body of guideline....................................................................................................4

4.1 Sub heading 2..................................................................................................4

5. Monitoring and the effectiveness of this guideline..................................................4

5.1 Sub heading 2..................................................................................................4

Appendix 1: Glossary of Terms..................................................................................5

Appendix 2: Other linked trust policies and guidelines...............................................6

Appendix 3: Extra sources of information and support...............................................7

Appendix 4: Privacy Impact Assessment and Equality Analysis................................8



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1. Introductions and aims of guidelinePlease note that this is advisory information only. Your experiences may differ from those described. All exercises must be demonstrated to a patient by a fully qualified physiotherapist. We cannot be held liable for the outcome of you undertaking any of the exercises shown here independently of direct supervision from the RNOH.

As a specialist orthopaedic hospital we recognise that our broad and often complex patient group needs an individualised rehabilitation approach. Our emphasis is on patient-specific rehabilitation, which encourages recognition of those patients who may progress slower than others. These rehabilitation guidelines are therefore ‘milestone driven’ and designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the outpatient clinic at RNOHT by helping the patient and therapist to identify when specialist review is required.

2. DefinitionsSee Section 4

3. Duties and ResponsibilitiesThis section N/A for this guideline

4. Body of guidelineIndications for UKR Surgery

Unicompartmental pain / Osteoarthritis (OA)

Indications for PFJ Surgery

Patellofemoral joint pain / OA

Indications for TKR Surgery



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Pain on mobilising

Restricted range of movement

Tibial and/or femoral OA

Functional Restrictions

Progression from a UKR

Possible complications of Surgery:

Infection

Bleeding

Nerve damage

Deep Vein Thrombosis

Pulmonary embolism

Persistent/ Recurrent Pain

Failure of prosthesis

Patello-femoral instability and other complications

Peri-prosthetic fractures, especially of the femur (supracondylar)

Neurological complications: peroneal nerve palsy / altered sensation post-op

Surgical Techniques

TKR e.g. PFC, Triathlon, Vanguard, Genus II

The most common form of total knee replacement is the unconstrained The femoral and tibial components are not joined together therefore the stability of

the knee comes from patients own ligamentous support

Constrained TKR e.g. SMILES

These tend to be used in patients with poor ligamentous stability and/or severe joint deformity

The femoral and tibial components are joined together with a hinge to give stability that would otherwise have been provided by patients own ligaments.

Due to its constrained nature normally patients will be restricted to achieve knee flexion to 90° with this prosthesis, but not always the case.

Will often allow hyperextension



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UKR

Medial or lateral compartment replaced, therefore one femoral condyle metal component and one tibial metal component, with or without a patella component. This replacement often has a plastic spacer attached to the metal tray of the tibial component which can be replaced if worn.

Offers normal knee kinematics Bone stock preserved and much less surgical dissection

PFJR

Front of trochlea groove removed and resurfaced with metal component. Posterior surface of patella may also be resurfaced

Bone stock preserved and much less surgical dissection

Pre-Operatively

If part of the Enhanced Recovery Programme, patients will attend ‘Joint School’. These patients will be given information from the MDT including nursing staff, anaesthetists, pharmacists, pain nurses, physiotherapists and Occupational Therapists.

Where possible the patient will be seen pre-operatively on the ward, and with consent, the following assessed:

Current functional levels General Health Social / Work / Hobbies Range of movement/ Muscle strength Exercises taught and exercise sheet issued Post-operative management explained Functional including: Balance/ Proprioception/ transfers as indicated

Gait/ mobility, including walking aids, orthoses

Clarify post-operative needs, goals and expectations



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If unable to review pre-operatively this will be assessed post-operatively.

Post-operatively

Always check the operation notes, and the post-operative instructions. Discuss any deviation from routine guidelines with the surgical team concerned.

Inpatient Stay (usually 3-5 days)

Goals

To achieve 90° knee flexion and 0° knee extension – comparable with pre-op status.

If longstanding history of restricted terminal extension or flexion exists, this may not be achieved prior to discharge. In these cases the expected range of movement should be clarified with the surgical team.

To be safe and independently mobile with an appropriate walking aid To be able to safely ascend/descend stairs with an appropriate aid if required To be independent with a home exercise programme (HEP) as appropriate To understand self-management / monitoring

Restrictions

* Always check operation notes and post-op instructions

Ensure WB restrictions are adhered to, usually FWB Do not rest with pillow under knee Constrained TKR may be slightly slower to rehab and discharge due to more

extensive procedures

Treatment

Pain Relief: Ensure adequate analgesia Elevation: Ensure elevation of the leg with foot higher than the waist Exercises: Circulation, AROM/AAROM knee flexion and extension in

lying/sitting, static quads, co-contraction of quads/hamstrings, strengthening Gait Re-education CPM: if indicated



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Education: Teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned.

Swelling management: Teach Protection, Rest, Icing, Compression and Elevation (PRICE)

Mobility: Ensure patient is independent with transfers and mobility with an appropriate aid/s, including stairs if necessary, able to safely transfer with aid/s, supervision/assistance

On discharge from the ward

Independently mobile and safe with appropriate aid/s, including ascent/descent of stairs as necessary

Independent with transfers Independent with a HEP Achieving 90° flexion and full active extension (re: pre-op)

Follow-up Physiotherapy:

Patients will be referred for follow-up physiotherapy in accordance with treating physiotherapist’s clinical reasoning. Reasons for referral to outpatient physiotherapy could include: difficulty achieving ROM, poor quadriceps function, functional deficit compared to pre-op mobility levels, deterioration of neurovascular status i.e. foot-drop and difficulty with independent HEP

Initial Rehab Phase: 1- 6 weeks

Goals

At 6 weeks 0° knee extension comparable to pre-op status (if longstanding history of restricted terminal extension exists, this may take longer than 6 weeks to achieve)

Increasing flexion; o Unconstrained TKR/ UKR/ PFJR: as much flexion as possibleo Constrained TKR: may be limited to 90° maximum flexion due to the

nature of the prosthesis To wean from walking aids as comfort, swelling and knee control allows, with

normal gait To be independent with a home exercise programme (HEP)

Restrictions



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No kneeling / sitting cross-legged for 6 weeks Employment - If sedentary employment, may be able to return to work 6 weeks

post-operatively, as long as provisions are made to elevate leg, and no complications.

Driving: not to drive for 6 weeks following surgery.After 6 weeks may be able to return to driving a manual car if mobilising with no aids, has adequate knee ROM and would be able to perform an emergency stop. May be able to return to driving an automatic sooner than a manual if the braking pedal is used by the unaffected leg.

Otherwise direct patient to ask consultant if fit to drive.

The patient should be advised to inform their insurance company of the procedure they have undergone to ensure their cover is valid.

Treatment

Advice / Education: Comprehensive education and instruction on restrictions and on carrying out activities of daily living (to avoid activities that can provoke excessive shear forces or impact).

Posture advice / education. Swelling management: continue encouraging PRICE and minimise activity

related effusion Gait re-education. Stretches of tight structures as appropriate. Mobility: Ensure safely and independently mobile with/without walking aid.

Exercises: o Knee ROM exercise to ensure achieving full range of extension and

progressing ROM into flexion. o Strengthening of muscles stabilising the kneeo Proprioception and balance exercises, progressing to an unstable base

of support and entre of gravity shift as appropriate Manual therapy

o Soft tissue techniques as appropriateo Joint mobilisations as appropriate

Core Stability as appropriate Hydrotherapy if appropriate Pacing advice as appropriate Electrotherapy as appropriate

Milestones to progress to next phase

Achieving stated ROM Rehabilitation Guidelines for patients undergoing Total Knee Replacement (TKR),

Patellofemoral Knee Replacement (PKR) or Unicondylar Knee Replacement (UKR) | Page 10

Date Approved 25/09/2014Version 1.0

Mobility with/without aids

Final Rehab Phase 6 weeks +

Goals

Extension: 0° knee extension comparable to pre-op status (If longstanding history of restricted terminal extension exists, full terminal extension at 6 weeks + may not be achieved)

Flexion:o Maximal range of movement for TKR/ UKR and PFJR comparable with

pre-op status (if long-standing history of loss of flexion discuss with surgical team)

o Constrained TKR can often be limited to 90° maximum flexion due to the nature of the prosthesis.

To be safe and independently mobile without an aid (as comparable with pre-op status)

To be able to ascend/descend stairs reciprocally To be fully independent with activities of daily living (comparable with pre-op

status)

Restrictions

Joint replacement components have no capacity to heal from injury sustained after surgery; therefore we offer some common-sense guidelines for athletic, leisure, and workplace activities:

Recommended: Permitted: Not recommended: Swimming Water aerobics Cycling or stationary

bike Golf Dancing Sedentary occupations

(desk work)

Hiking Gentle Jogging Gentle doubles

tennis Gentle downhill

skiing Light labour

(jobs that involve driving, walking or standing but not

Long distance running

Impact exercises Sports that require

twisting/pivoting (aggressive tennis, basketball, racquetball)

Contact sports Heavy labour



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heavy lifting)

Treatment

Pain Relief Gait re-education Exercises:

o Dynamic and rhythmic stabilisation exerciseso Strengthening through rangeo Stretches of tight structures as appropriate

Balance and proprioception: as appropriate PFJ/ UKR (up to high level) TKR (low level) o Introduction of unstable base including use of wobble boards, sit-fit

cushions, gym-ball, trampette (progress with distractions turning head/throwing/catching/reaching as appropriate

Functional:o Unrestricted sitting cross-legged, kneeling, getting-up from floor

Posture Advice/ Education Hydrotherapy as appropriate Pacing advice as appropriate Return to Work: introduction of occupation specific rehabilitation Gentle recommended and permitted sports: introduction of sport specific

rehabilitation. See above restrictions

Milestones for discharge

Achieved goals Return to normal functional level and sports, if set as a patient goal

5. Monitoring and the effectiveness of this guideline

Failure to progress

If a patient is failing to progress, then consider the following:

POSSIBLE PROBLEM ACTION



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Swelling Ensure elevating leg regularly.

Use ice as appropriate if normal skin sensation and no contraindications.

Decrease amount of time on feet.

Pacing.

Use walking aids.

Circulatory exercises.

If decreases overnight, monitor closely.

If does not decrease over a few days, refer back to surgical team

Pain Decrease activity.

Ensure adequate analgesia.

Elevate regularly.

Decrease weight bearing and use walking aids as appropriate.

Pacing.

Modify exercise programme as appropriate. Should continue isometric work at all times.

If persists, refer back to surgical team.

Breakdown of wound e.g. inflammation, bleeding, infection

Refer to surgical team.

Recurrent Instability Refer back to surgical team.

Ensure exercises not too advanced for patient.



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Address core stability.

Numbness / altered sensation Review immediate post-operative status if possible.

Ensure swelling under control.

If new onset or increasing refer back to surgical team.

If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned.



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Appendix 1: Glossary of Terms

Please add text here.



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Appendix 2: Other linked trust policies and guidelines

Other orthopaedic rehabilitation guidelines for knee surgery would sit here

Link to rehabilitation guidelines for all other teams



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Appendix 3: Extra sources of information and support

Summary of evidence for physiotherapy guidelines

A comprehensive literature search was carried out to identify research relating to rehabilitation following arthroplasty of the knee. After reviewing the articles and information, the physiotherapy guidelines were produced on the best available evidence.

Cooney, W. P Sierra, R.J. Trousdale, R.T. Pagnano, M. W (2005) ‘Revision Total Knees done for Extensor Problems Frequently Require Reoperation’ Clinical Orthopaedics and Related Research, 440 pp – 117-121

Grella, R. J (2008) ‘Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation?’ Physical Therapy Reviews 13 (4) pp- 269-79

Isaac, S. M, Barker K. L, Danial I . N, Beard D. J, Dodd, C.A Murray, D. W (2007) ‘Does arthoplasty type influence knee joint proprioception?’ The Knee, 14 pp: 212-217

Keene, G. Forster, M (2005) ‘(iii) Modern Unicompartmental knee replacement’ Current Orthopaedics, 19, (6), pp - 428-445

Kreibich, D N. Vaz, M. Bourne, R B. Rorabeck, C H. Kim, P. Hardie R. Kramer, J. Kirkley, A. (1996) ‘What is the best way of assessing outcome after Total Knee Replacement?’ Clinical Orthopaedics and Related Research, 331, pp – 221-225

Lenssen, T.A. Van Steyn, M. Crijns, Y. Waltje E. Roox, G.M, Geesink R. J, Brandt, P. A (2008) ‘Effectiveness of prolonged use of CPM as an adjunct to Physiotherapy, after Total Knee Arthroplasty’ BMC Musculoskeletal Disorders, 60 (9) pp-

Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G, Tugwell P (2008) Continuous passive motion following total knee arthroplasty. Cochrane Database of Systemic Reviews Issue 2

Mullaji , A.B, Sharma, A. Marawar, S. (2007) ‘ Unicompartmental Knee Arthroplasty Functional Recovery and Radiographic Results with a Minimally Invasive Technique’ The Journal of Arthroplasty, 22, (4) pp-7-11

NHS (2008)

http://www.nhs.uk/Conditions/Knee-replacement/Pages/Whathappens.aspx Rehabilitation Guidelines for patients undergoing Total Knee Replacement (TKR),

Patellofemoral Knee Replacement (PKR) or Unicondylar Knee Replacement (UKR) | Page 17

Date Approved 25/09/2014Version 1.0

http://www.nhs.uk/Conditions/Knee-replacement/Pages/Whathappens.aspx

Patient UK (2008) (http://www.patient.co.uk/doctor/Knee-Joint-Replacements-What-a-GP-Needs-to-Know.htm_

Appendix 4: Privacy Impact Assessment and Equality Analysis

Please add text here.



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http://www.patient.co.uk/doctor/Knee-Joint-Replacements-What-a-GP-Needs-to-Know.htm_

http://www.patient.co.uk/doctor/Knee-Joint-Replacements-What-a-GP-Needs-to-Know.htm_

This guideline is available on request in large print and alternative languages. It is a manager’s responsibility to ensure employees are aware of these options.

* The following policies must be sent for review to the Local Counter Fraud Specialist:

Fraud and Bribery

Standard Financial Instructions

Declaration of Interests

Gifts and Hospitality

Whistleblowing

Disciplinary

IT

Anti-Money Laundering

Managing Sickness Absence

Secondary Employment

Expenses

Overpayment

Financial Redress

TOIL (Time off in Lieu)

Code of Conduct/Standards of Business Conduct

Data Protection

Lone Worker

Patient Transport

Commercial Sponsorship

Overseas Visitors

Disclosure



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