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 2003.pain 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 Sup.Ly.
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