knee replacements/Total Knee Arthroplasties (TKA)

etiology

often 2/2 OA, degenerative joint disease, trauma, or injury to the knee, or other rheumatic conditions

• may be compounded by obesity or aging

2 types

• partial or uni-compartmental knee arthroplasty (UKA)

  • client has medial or lateral compartmental damage between femur and tibia

  • UKA is often performed with minimally invasive technique

• total knee replacement or arthroplasty (TKA)

  • client has damage to 2 or more compartments of the knee

  • minimally invasive techniques have been developed for TKA

medical management

goals of treatment= to alleviate pain, increase motion, and maintain alignment and stability of the knee joint

• involves cutting away damaged bone and attaching prosthetic component of new joint

• ambulatory device (walker or crutches) may be used for greater stability

• knee immobilizer or brace may be used if knee joint is unstable post-surgery

• client should avoid excessive knee rotation for up to 12 weeks after surgery

• usually no restriction on flexion and extension of knee; clients will usually start out-of-bed activity on the 1st day after surgery (sometimes even sooner)

  • mobility of knee is important

  • some surgeons will recommend use of continuous passive motion device (CPM) to improve ROM

pain

• cryotherapy in acute recovery,

  • in acute stage, there is still lots of swelling and inflammation

  • DO NOT use heat— contraindication, as it increases the amount of blood flow and circulation coming into the area (would cause more swelling)

• balancing pain and activity

positioning

precautions to promote proper healing; knees are “straightforward” in 3 ways

1. they’re simple and straightforward

2. we keep them in extension at rest (keep them straight)

   1. it is easier to get a stiff knee to flex than it is to extend

   2. we position the knee in full extension while at rest to avoid a flexion contracture/stiffness

   3. DO put pillows distal to the knee (promotes extension)

   4. DO NOT put pillows under the knee (promotes flexion)

3. we avoid twisting movements (keep them forward)

performance/ADLs & AE

functional, ADL focus

• the main problem besides mobility/transfers is reaching the affected LE

• we use AE to compensate for limited ROM

  • dressing

    • shoe horn

    • sock aid

    • reacher

    • dressing stick

  • bathing

    • long-handled sponge

• also train to don/doff knee immobilizer

early movement and transfers

we can typically get moving early; out of bed post-op day 1

• WBAT is common, but still check physician’s orders

• transfers (sit-stand) are of obvious concern

  • use UEs

    • armrests

    • handholds/grab bars

  • toileting

    • toilet safety frame

    • raised toilet seat

    • commode chair

  • bathing

    • non-slip strips

    • side-step into tub (instead of facing the tub)

non-weight bearing

no weight on affected extremity

toe-touch weight bearing

toe of the affected extremity can touch the ground for balance only; 90% of the body weight is placed on unaffected leg

partial weight bearing

affected extremity may bear only 50% of client’s body weight

weight bearing at tolerance

client judges how much weight they can tolerate on the basis of pain response

full weight bearing

client may put 100% of weight on the affected extremity without causing damage

role of OT

1. help client maximize performance skills in occupations while maintaining precautions

2. complete an OTPF with the client and family or caregiver

3. consider psychosocial impact on lifestyle

4. provide education and reeducation regarding weight bearing restrictions and precautions, including with

   1. bed mobility

   2. proper transfer techniques

   3. home modification recommendations

   4. positioning to perform ADLs

5. emphasize increasing independence and participation in ADLs and IADLs

   1. teach prescribed precautions, safety techniques, and compensatory strategies for IADLs such as lower-body dressing, bathing, sexual activity

   2. alternative options for bathing (e.g., dry shampoo, rinse-free shampoo cap, washing hair in the sink) may be considered for clients unable to shower in a tub or walk-in shower

6. emphasize maintaining or increasing joint motion

7. increase strength of surrounding musculature

8. prescribe and instruct the client (and family or caregiver, as necessary) in use of AE

9. provide home safety recommendations

10. assist in return to work

11. address and assist with return to driving and community mobility