TOTAL KNEE REPLACEMENT (TKR)

PRESENTED BY: ZURIATI BINTI ZAKARIA

INTRODUCTION
Knee Joint (tibiofemoral jt.)
Largest and most complex joint of the body, actually consisting of 3 joints within a single synovial cavity:
Laterally tibiofemoral jt Medially 2nd tibiofemoral jt. Intermediate patellofemral jt

Classified as a modified hinge joint - Movement it allows flexion, extension, slightly medial rotation and lateral rotation of leg in flexed position.

What Is Total Knee Replacement?

- Surgical procedure where worn, diseased,or damaged surfaces of a knee joint are removed and replaced with artificial surfaces. - It have 2 type of replacement
- 1) Partial Replacement - 2) Total Repalecement

The "artificial joint or prosthesis" generally has two components, Cobalt -chrome or titanium Plastic material called polyethylene

Indication of surgery
Severe pain Osteoarthritis Gross instability or limitation of motion Genu varum and valgum Failure of a previous surgery prosedure

Complication of Total Knee Replacement

Thrombophlebitis Infection Stiffness Loosening

Medical Treatment

Anti-inflammatory medication may reduce the inflammation from the arthritis and reduce pain.

Post operative management

- During period of immobilization - Quadricep setting exs - Straight leg raising - Ankle pumping exs - ambulation - Exs to increase ROM
- To increase ROM of knee flexion and extension

- Exercises for increase strength

SLR Resistance exs Exs. on stationary bicycle Active stretching

Case study
Name : Mdm. Q Age : 66 yrs old Sex : Female Race : Chinese Date of admitted : 10.July.2006 Date of assessment : 13.July.2006 Doctor diagnosis : Chronic Lt. knee OA Doctor management :Lt.TKR done on 12.July 2006

Problem 1. Pt. c/o pain at operation site of Lt. knee jt SUBJECTIVE ASSESSMENT Current Hx : - Patient admitted to ortho ward HTAR on 10/07/06 due to elective surgery for Lt. TKR - On POD 1 for Lt. TKR Past Hx :- h/o bilateral OA knee since 10 yrs ago

Past med./surgical Hx:- Hypercholesterolemia present - Rt. TKR have done 2 yrs ago (2004)
Social Hx:- Married with 3 children - Housewife - Stay with her husband and son - Non smoker and non alcoholic - Lives in double storey house but she stay at ground floor - Toilet : sitting

Medication:- Zintact Dr. Investigation:- x-ray done 12 July 06 : Lt. knee TKR well

Vital sign:- BP : 140/80 mmhg - PR : 84 bpm - RR : 20 bpm - T : 37 c

OBJECTIVE ASSESSMENT Gen.Observation - Chinese, thin size of body, alert and cooperative and in sp. lying position on bed - On IV drip on Lt. hand - On redivac drainage and IV CBD - Pt. able to move both upper limb and LL actively Local Observation - Lt. LL immobilize with bandage and cover by knee brace - Pt. able to move Lt. ankle dorsi and plantarflex actively - No swelling seen over the Lt. ankle jt and foot

RANGE OF MOTION - Both UL AFROM - Joint Rt. Hip : Flexion Extension AFROM Abduction Adduction Knee: Flexion 0 - 95 Extension AFROM Ankle: Dorsiflex Plantarflex AFROM Invertion Evertion

Lt.
Unable to measure d/t immobilize Unable to measure d/t immobilize AFROM

Muscle Strength (oxford scale) - Both UL Grade 5/5 - Joint Rt. Hip : Flexion Extension Grade 4/5 Abduction Adduction Knee: Flexion Grade 4/5 Extension Ankle: Dorsiflex Plantarflex Grade 4/5 Invertion Evertion

Lt.
Unable to test d/t immobailize
Unable to test d/t immobailize

Grade 5/5 with pain

Problem Listing - Pain at the operation site of the Lt. knee - Reduce muscle strength of the unaffected limb

Short Term Goals - To reduce pain - To improve circulation - To improve muscle strength of isomectric contraction of muscle of jt. immobilize - To increase range of motion of Lt.knee movement after immobilize - To improve and maintain muscle strength for both UL and Rt. LL - Ambulate pt. by using walking aids

Long Term Goals

To regain back normal mobility of lower limb and functional of ADL

Plan of Treatment - Circulatory exercise - Static Quadricep exs and IRQ - Passive knee extension exs - Passive knee flexion exs - SLR - Active free exercise for both upper limb and unaffected site - Mobilizing exs - Encourage ambulation - Pt education

Progression Note 13.July.06

s o a p

same as initial assessment

1. circulatory exercise :- pt ly; both ankle pumping (hourly) 2. static quads (isometric exs) :- pt ly. press down Lt. knee, hold 10 sec ( 10times / hourly)

:- long sitt; press down the heel on bed (10sec hold,10time/hourly) 4. Active free exs for both UL and Rt.LL :- long sitt; Sh.abd and add :- long sitt; Sh.flex and ext. :- ly; Hip flex. and ext. (for Rt. LL) :- ly; Hip abd. and add. (for Rt. LL) (30 times/session/day) 5. pt. education :- advice pt to do exs regularly

Progression Note

14.July.06

S :- c/o pain around op.site while move of affected knee. :- POD 2 Lt.TKR O Gen / local Observation :- Chinese women,alert,co operative, 1/2 ly. on bed. :- on Iv drip and CBD :- ant.aspect of the Lt.knee jt. cover by gauze :- swelling around knee Lt. jt :- mobility of Lt.LL improve than before :- on palpation: warmth around the Lt. knee jt. : tenderness at med. aspect Lt. knee jt.

RANGE OF MOTION - Both UL AFROM - Joint Rt. Hip : Flexion Extension AFROM Abduction Adduction Knee: Flexion 0 - 95 Extension AFROM Ankle: Dorsiflex Plantarflex AFROM Invertion Evertion

Lt.

PFROM

15 70 act 0- 80 passive

Lag 15

AFROM

Muscle Strength - Both UL Grade 5/5 - Joint Rt. Hip : Flexion Extension Grade 4/5 Abduction Adduction Knee: Flexion Grade 4/5 Extension Ankle: Dorsiflex Plantarflex Grade 4/5 Invertion Evertion

Lt.
Grade 2/5

Grade 2/5
Grade 2/5

Grade 4/5

A :- pain at ant. aspect d/t incision of ops.

:- slightly swelling around Lt. knee d/t inflammation :- limitation of movement of Lt. knee d/t pain
P 1. Knee flexion exs (gentle) :- long sitt ; move Lt. knee flex and ext ( 20 time / hourly) 2. circulatory exercise :- long sitt on bed; both ankle pumping (every hours) 3. static quadrisep :- long sitt; press down Lt. knee (10 sec hold,30 times / hourly) 4. IRQ :- long sitt; press down the knee and ext with ankle dorsiflex (roll of towel under the knee jt.)

5. Passive knee ext. exs :- long sitt; place towel under the foot,use a slow sustained push with the hand downward on the quadriceps

6. Active free exs for both UL and Rt.LL :- long sitt; Sh.abd and add :- long sitt; Sh.flex and ext. :- ly; Hip flex. and ext. (for Rt. LL) :- ly; Hip abd. and add. (for Rt. LL) (30 times/session/day)
8. pt education :- advice pt to do exs regularly like before until at home