presentation at Hosp Sultanah Bahiyah

Adlin Hani binti Mazlan Hanafi2011445252

UiTM Puncak AlamPTY 309

Osteoarthritis with Total Knee Replacement (TKR)

ANATOMY

• Knee joint is the largest and most complex joint.• The upper bone is the femur and the lower bone is the tibia. The small bone at the

lateral side is the fibula. The knee cap (patella) is in front of the knee.• There are large muscles in the front of the thigh (the quadriceps) and back of the

thigh (the hamstrings).• Ligaments join the knee bones and provide stability to the knee:

-The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the tibia sliding forward on the femur).-The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur).-The medial and lateral collateral ligaments prevent the femur from sliding side to side.

• Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia.

• Numerous bursa, or fluid-filled sacs, help the knee move smoothly.

(G. J Tortora, 2009)

PATHOPHYSIOLOGY• Osteoarthritis is a deterioration and changes happened mostly at the knee

where articular cartilage that cushions the bones breaks down, and causes the bones to rub together.

• Articular cartilage is living tissue. The growth and repair will decreases with age.

• Elasticity and viscosity of synovial fluid changes as hyaluronic acid concentration decrease.

• This results in the formation of ulcers that extend deep into the bones.• The surfaces of the knee gradually "wear out“ and creates pain, swelling,

and stiffness.• Weight-bearing activity becomes painful, often limiting physical activity.• After a while bone spurs may form and ligaments and muscles around the

joint become weaker. (OA health Center, 2009)

Total Knee Replacement• Osteoarthritic of the knee is the commonest reason which

necessitates knee replacement.• Total knee replacement (TKR) is a surgery where only the worn-out

cartilage surfaces of the joint are replaced.• The operation (also called knee arthroplasty) is basically a "re-

surfacing“ of the knee joint because only the surface of the bones are actually replaced.

• When the patient having a TKR, the surgeon removes damaged cartilage and bone from the surface of the knee joint and replaces them with a man-made surface of metal and plastics.

• A small amount of bone is removed, the collateral ligaments are left intact, and the muscles and tendons are left intact.

(AAOS, 2011)

Clinical Presentation• Pain is felt around the knee join• Joint stiffness usually lasts less than 20 minutes• Limitation of movement• Loss of function• Affected joints may have tenderness and firm swellings at the joint• Decreased range of motion (ROM).• Worse with weight bearing and ambulation. • May be cartilaginous crepitus or a crackling feeling on palpation. There

may be coarse.• Malalignment of the leg with a varus deformity or bow-legged positioning

of the leg d/t loss of cartilage.

(OA health Center, 2009)

Dr Management• Other treatment options before surgery :

i) Medications : NSAIDsii) Medications injected into the joint : Corticosteroid injections fight inflammation iii) Creams or ointments to rub onto the skiniv) Exercise and physical therapy : Exercise strengthens the muscles that support the kneev) Weight loss : Every pound a person gain puts an extra 3 pounds of pressure on the kneesvi) Nutritional supplements

• If these treatment options don't relieve the pain well, less effective, not tolerable, the doctor may suggest surgery. i) arthroscopic surgery : involves small incisions to remove pieces of cartilage and trimmed the damage tissue to smoothen the joint surfacesii) knee replacement surgery : replacing the damaged parts with an artificial joint. These are made of metals and plastics

(OA health Center, 2009)

PT Management• Exercise to improve strength, flexibility balance and maintain joint motion• Electrotherapy• Taping• Use of a knee brace or compression bandage• Ice or heat treatment• Hydrotherapy• Education• Anti-inflammatory and supplement advice (e.g. glucosamine and

chondroitin)• Weight loss

( Leonard Ong Yao Jian, 2011)

CASE STUDY

Subjective AssessmentName : Mrs. JAge : 60 years oldGender : FemaleR/N : AS00******Location : Outpatient ( Gymnasium)D.O.A : 28/04/2013D.O.R : 04/02/2013Race : IndianDr. Diagnose : Bilateral knee OADr. Mx : TKR Rt knee. Planned for Lt knee 6 months after.

Patient’s Problem :1. Pt c/o mild uncomfort at both knee during walking2. Pt c/o need mild assisstance during sitting to standing3. Pt c/o need assisstance to climb up stairs

BODY CHART

VAS : (Rt) 0/10- rest 3/10- on movement (Lt) 0/10- rest 4/10- walkingAgg : bend Rt knee towards 90°Ease : rest/sitting Nature : pulling pain on both side posterior thighIrritability : low24 h : intermittent pain (depends on movt) TKR incision site

Current History : Pt done post TKR for Rt knee on 29/01/2013. Having complicated patella tendon medial 30% tear on Rt knee during manipulation, repaired with prolene 2/0. After 3 months, pt able to walk without walking aids. She is having good improvement. Pt is not allowed to do Rt knee flexion more than 90° yet. Doctor planned for Lt knee TKR, 6 months after the Rt side which is on Aug 2013.

Past History : Having bilateral knee OA since 2011. Intraarticular injection hyaluronic acid was given 1x on 31/10/2011 but was not helpful. No history of fall or accident.

PM History : Rt breast carcinoma. Done mastectomy and axillary clearance on 2009. on follow-up every 6 months - on T.tamoxifen 20mg OD

Special QuestionGeneral health: healthyWeight loss : nilSmoking : nil

Social HistoryOccupation : Retired officerStatus : Married. Having 2 daughters and a son.House Environment : single storey house – staying with husband and a daughter Activities : Indoor activities. Not involved any vigorous activities.

Observation General : A medium sized old Indian lady came to department independently. Walking without aids. Walking with slight limping gait towards Lt side, slow and careful. Looks healthy and cooperative.

Local : No swelling, no redness, no dry skin on both knee.

Palpation : No warmness, no tenderness, no muscle spasm on both knee

Objective AssessmentRange of Motion (ROM)

Joint Movement Rt active Rt passive Lt active Lt passive Normal

Hip Flexion AFROM - AFROM - 0-120°

Extension “ - “ - 0-20°

Abduction “ - “ - 0-45°

Adduction “ - “ - 0°

Knee Flexion -10°-75° -10°-75° -40°-90° -40°-90° 0-120°

Extension Ext lag 10° - Ext lag 40° - 0°

Ankle Dorsiflexion AFROM - AFROM - 0-20°

Plantarflexion “ - “ - 0-50°

Int : Reduce joint ROM both knee d/t pain and muscle tightness

Manual Muscle Testing (MMT)

Muscle Rt Lt

Hip Flexor 5/5 5/5

Extensor “ “

Abductor “ “

Adductor “ “

Knee Flexor 4/5 (with limit ROM) 4/5 (with limit ROM)

Extensor 4/5 (with limit ROM) 4/5 (with limit ROM)

Ankle Dorsiflexor 5/5 5/5

Plantarflexor “ “

Int : Reduce muscle power knee flexor and extensor both knee d/t muscle weakness

Muscle Bulk

From base of patella

Rt (cm) Lt (cm) Differences

5 cm (VMO) 51.0 51.5 0.5

10 cm (Quadriceps)

53.0 53.0 0

15 cm (Hamstrings)

55.0 55.0 0

From apex of patella

13 cm (Gastrocnemius)

41.5 40.5 1.0

Int : Normal muscle bulk for both LL

Patella mobility

Movement Rt Lt

Superior glide Less mobile Crepitus

Inferior glide Less mobile Crepitus

Medial glide Less mobile Crepitus

Lateral glide Less mobile Crepitus

Int : Crepitus found on Lt knee d/t degenerative changes Less mobile of patella on Rt knee d/t lack of activities

Sensation test : Hot and Cold

Special testLt KneePatella Grinding Test : +ve

Dermatome Rt Lt

L1 Intact Intact

L2 “ “

L3 “ “

L4 “ “

L5 “ “

S1 “ “

S2 “ “

S3 “ “

Int: Skin sensation intact on both LL

Analysis ProblemImpairment Functional limitations Participation restrictions

Pain at Lt knee d/t degenerative changes

Unable to sit on the floor Unable to join family gathering

Reduce patella mobility on both Lt knee d/t degenerative changes

Difficult to perform sitting to standing from the chair

Difficult to meet friends and attend event

Reduce Rt and Lt joint ROM knee flexion and extension d/t prolonged immobilize

Difficult to perform sitting to standing from the chair

Difficult to meet friends and attend events

Reduce muscle strength for Rt and Lt knee flexor and extensor d/t muscle weakness

Difficult to climb up stairs Feel uncomfortable to go shopping

Limping gait d/t uneven weight bearing caused by pain

Unable to walk fast Feel tired to walk far and involved in any activities

Short Term Goal1. To reduce pain on Lt knee from 2/10 to 0/10 within 1/72. To improve joint ROM for Rt and Lt knee flexion and extension within

1/123. To reduce hamstring tightness on both knee within 1/124. To improve muscle strength for Rt and Lt knee flexor and extensor within

3/125. To improve walking pattern within 6/526. To maintain balance and weight bearing within 2/12

Long Term Goal7. To optimize maximum functional activity and improve ADL such walking

and sitting to standing.

PLAN OF TREATMENT INTERVENTION EVIDENCE BASED

Pain Management- Heat modalities

i) Hot packTo reduce pain & improve blood circulation of Lt knee-Pt. in long sit.,apply hot pack on skin of Lt knee, 20 mins.

The effects of thermotherapy are used clinically to control pain,increase soft tissue extensibility and accelerate healing.(Cameron M. ,2009)

Therapeutic Exs- Active exs

i) Knee flexion and extension- pt sitting on chair, perform knee flexion and extension actively; 20x; 3reps, 2x/day

‘Exercise to improve or eliminate impairments in thigh muscle flexibility and strength,and improve performance of endurance activities with repetitions.’ (James Rainville, MD,2004)


- Stretching exs i) Hamstring stretchTo reduce hamstring muscle tightness-Pt in long sit., towel at sole with both end hold by both hand, elevate leg till feel stretch at hamstrings, perform both LL, hold 15 secs, 15 mins

ii) TA stretchto maintain ankle joint ROM-Pt in long sit., towel at sole with both end hold by both hand, pull the end towel to stretch the TA, perform both LL, hold 15 secs, 15 mins

Holding stretches for 15 seconds, as opposed to five seconds, may result in greater improvements in active ROM. ( Roberts J M, 1999)


- Strengthening exs i) IRQTo improve quadriceps muscle strength-Pt. in long sit., both below knee supported with tumble foam, do alternate IRQ, 10 secs, hold, 15 mins

ii) VMO with ball To maintain VMO strength-Pt. in high sitt., put a soft ball between thigh, ask pt. to squeeze the ball, lift up both leg, hold 10 secs, 15 mins

For most tears, some simple exercises can help maintain muscle strength in the front of the thigh (quadriceps), back of the thigh (hamstrings), calf, and hip.( Freddie H. Fu, 2010)


Pt Education - Avoid to put more stress on Lt knee that may trigger the pain- Advice on wearing knee guard

HEP Continue exs as taught at home

Evaluation1. Pt able to follow command and understands the treatment2. Pt not complained any uncomfortable during exercise3. Pt can tolerate with the exercise given and willing to continue exercise at

home

ReviewPlanned to have next follow- up on 21/05/2013• KIV for posture analysis• Reassess on pt. both knee pain• Reassess on pt. ROM and muscle power for both knee• Reassess on pt. walking pattern for both LL• Continue all treatment done on next visit within pt toleration.

Follow Up21/05/2013S : i) Pt told that pain had reduced on Rt knee when walking from 2/10 to 0/10 ii) Pt c/o slight unstable during walking towards Lt side ii) Pt c/o pain at Lt knee had worsen with vas 4/10 when walking iv) Pt still claims of pulling pain at posterior thigh especially when get up from sitt.

O : Pt came to department independently w/o walking aids. Able to drive auto car alone. Her limping gait obviously seen d/t Lt knee had worsen the pain. Looks healthy and cooperative. She brought along referral letter from Dr to allow Rt knee flexion towards 90°. Palpation : no swelling, tenderness, redness, dry skin on both knee

Posture Anterior view : Left sh. is slight lower than right sh.

Lt ASIS is lower than Rt ASIS Lt knee is not align with Rt knee Lt knee not fully extended

Posterior : Lt scapula is slight lower than right side Lt sh is lower than Rt sh. Lt popliteal lower than Rt popliteal Weight bearing more on Rt LL

Lateral : Both knee not fully extended – Lt side more flexed than Rt side

ROM

MMT

Joint Action Rt active Rt passive Lt active Lt passive

Knee Flexion -5°-80° -5°-80° -35°-90° -35°-90°

Extension -5° -5° -35° -35°

Int : Reduce joint ROM for both knee flexion and extension d/t pain and muscle tightness

Muscle Rt Lt

Knee flexor 4/5 4/5

extensor 4/5 4/5

Int : Reduce muscle power knee flexor and extensor both knee d/t muscle weakness

Patella mobilityMuscle Bulk same as previous AX

A : I. Pain at Lt knee d/t degenerative changesII. Reduce joint ROM for Rt and Lt knee flexion d/t pain and muscle

tightness but has improves from last visitIII. Reduce muscle power for Rt and Lt knee flexor and extensor d/t

muscle weakness IV. Abnormal posture d/t muscle tightness and pain of Lt LL

Short Term Goal1. To reduce pain on Lt knee from 3/10 to 1/10 within 1/72. To improve joint ROM for Rt and Lt knee flexion and extension

within 1/123. To reduce hamstring tightness on both knee within 1/124. To improve muscle strength for Rt and Lt knee flexor and extensor

within 2/125. To improve walking pattern within 6/526. To maintain balance and weight bearing within 2/127. To correct posture within 6/52

Long Term Goal8. To optimize maximum functional activity and improve ADL such

walking and sitting to standing.


Pain Management- Heat modalities

i) Hot packTo reduce pain & improve blood circulation of Lt knee-Pt. in long sit., apply hot pack on skin of Lt knee, 20 mins.

The effects of thermotherapy are used clinically to control pain, increase soft tissue extensibility and accelerate healing.(Cameron M. ,2009)

Therapeutic Exs- Stretching exs

i) Hamstring stretchTo reduce hamstring muscle tightness-Pt in long sit., towel at sole with both end hold by both hand, elevate leg till feel stretch at hamstrings, perform both LL, hold 15 secs, 15 mins

‘Exercise to improve or eliminate impairments in thigh muscle flexibility and strength,and improve performance of endurance activities.’ (James Rainville, MD,2004


- Active exs i) Knee flexionTo improve knee ROM- Pt side ly on Lt side, perform Rt knee flexion actively, 20x; 3 reps/day

ii) Bean ball for knee flexion- pt sup ly, bean ball under both popliteal, actively perform knee flex and ext; 20x

Active range-of-motion exercises for the knee may reinforcing, with repeated gentle challenges to the end ranges of movement in Osteoarthritis of the Knee. ( Deyle, G D, 2000)

- Strengthening Exs i) Quad benchTo strengthen the quad muscles- pt sitt on quad bench, weight 1kg, hold for 8 secs, perform for both LL, 15mins

After acute symptoms subsided, exercises should be performed in open chain and closed chain positions to improve strength and endurance in isolated muscle groups and to prepare the patient for functional activities. (Kisner C. & Colby L. A.,2007)


ii) Hamstring benchTo improve ROM of knee flexion.pt sitt on hamstring bench, weight 1kg, hold for 8 secs, perform for both LL, 15mins

Pt Education Avoid to put more stress on Lt knee that may trigger the pain- Advice on wearing knee guard

HEP Continue exs as taught at home

Evaluation 1. Pt able to follow command and understands the treatment2. Pt not complained any uncomfortable during exercise3. Pt can tolerate with the exercise given and willing to continue exercise

at home

Review

1. Reassess on pt ROM and muscle power for both knee2. Reassess on Lt knee pain 3. Reassess on pt. walking pattern for both LL4. Continue all treatment done on next visit with pt toleration.

Conclusion

Total knee replacement has proven to be successful and beneficial to modern surgery. Even not all patients with osteoarthritis get back their normal knee actions as normal person, but most patients enjoy many years of painless knee function with no limits on their ability to stand, walk and perform other activities of normal daily living. The rehabilitation programme may takes time but the effectiveness of TKR more or less will depends on the patients compliance itself. The most important thing is the physicians have to let the patients know that TKR is a life-enhancing surgery, not life-saving surgery.

References • Anonymous (n.d). Total knee replacement, Joint Replacement Institute, St Vincent

Medical Center. Retrieved May 1, 2013 http://www.jri-docs.com/knee/KneeReplace ment/Resources /Pages/TheGoalsofTotalKnee Replacement.aspx

• Anonymous, (2011). Total knee replacement, American Academy of Orthopedic Surgeon. Retrieved May 2, 2013, http://orthoinfo.aaos.org/topic.cfm?topic=a00389

• Anonymous, (2012). Total knee replacement, Southern California Orthopedic Institute. Retrieved May 10, 2013, http://www. scoi .com /total-knee-replacement.php

• Carolyn Kisner and Lynn Allen Colby (2002). Therapeutic Exercise, Foundations and Techniques. 5th Ed. Davis Company, Philadelphia.

• G. J. Tortora and B. H. Derrickson (2009).Principles of anatomy and physiology. 12th Ed. John Wiley and Sons, Inc.

• Palmer S.H. (n.d). Total knee replacement. Retrieved May 12, 2013, http://www.kneeclinic.com.au/papers/TKR/tkrchapter.htm

• Zelman, D. (2013). Knee Osteoarthritis: When to Consider Surgery. Retrieved April 30, 2013, Webhttp://www.webmd.com/osteoarthritis/osteoarthritis-knee-replacement-surgeryMD

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