62 Rehabilitation Following Total Knee Arthroplasty
P. Hernigou, A. Poignard, A. Nogier
Summary
Total knee arthroplasty consistently provides favorable outcomes of reduced pain, improved function, and en- hanced quality of life for arthritic patients. Although the technical aspects of the operative procedure contribute greatly to the outcome, perioperative rehabilitation re- mains an important adjunct. Successful rehabilitation in- volves the collaborative efforts of the surgeon, physical therapist,nursing staff,and patient.Rehabilitation proto- cols should be specific to reduce ambiguity, yet flexible to accommodate differences in patient characteristics. Crit- ical pathways have been designed to move patients through acute care in a more rapid manner, and in most cases they rely on subacute care facilities to complete pa- tient rehabilitation. This has led to a significant increase in the use of extended care, rehabilitation, and transi- tional care facilities in order to reduce length of stay and cost while still optimizing the functional outcome after total knee arthroplasty.
Differences in Patient Characteristics Affecting Rehabilitation
Because patient characteristics such as age and preoper- ative diagnosis have been shown to affect the results of to- tal knee arthroplasty, this information should be used to optimize the rehabilitation protocol and expectations of total knee arthroplasty. Most patients who do not have surgical complications easily accomplish the expected re- habilitation goals of a given postoperative day, resulting in a discharge from the hospital on the scheduled date.
However, patients who have surgical complications often do not fare as well.
Patients who experience unexpected perioperative problems or outcomes understandably are disappoint- ed. Patients with low preoperative knee scores or elder- ly patients should be informed that their hospital stay may be longer than that of most patients, or that they may not be discharged to home. This determination should be made as early as possible. When patients are given an appropriate expectation before surgery, they
are better able to cope with unexpected issues that may arise after surgery.
Some preoperative factors can predict patient satis- faction, function, and working capacity. There is a posi- tive association between the duration of preoperative and postoperative sick leave of patients who returned to work.
Satisfaction is greater among patients who return to work after surgery. Many investigators have studied correla- tions between patient age, gender, marital status, body mass index,and co-morbidity and the length of stay in the surgical unit and the need for inpatient rehabilitation [1, 2, 6, 11, 13]. Age was the only factor that correlated with hospital length of stay, while age and diabetes mellitus correlated with the need for inpatient rehabilitation.
However, there were no age-related differences in joint pain, function, or quality-of-life measures either before the operation or 6 months after it. Because these patients can be identified preoperatively, one may be able to preempt discharge delays by aggressively treating these patients (physical therapy, occupational therapy, social service, medical consultation). These findings indicate that a single standard allowable length of stay for all pa- tients undergoing total knee arthroplasty is not realistic.
Techniques of Rehabilitation
Although rehabilitation is usually targeted at postopera- tive recovery, the efficacy of preoperative physical thera- py has been investigated in some studies [6, 11, 23]. Some practitioners advocate a preoperative physical therapy program to maximize muscle strength and educate patients about what to expect immediately following surgery. However, no improvement in the outcome of total knee arthroplasty was found when patients had absolved a preoperative physical therapy strengthening protocol for 6 weeks compared with the outcome when patients had had no preoperative exercise [17].
The early postoperative phase of rehabilitation after
total knee arthroplasty may be started on the day of
surgery, with emphasis on pain control, ankle pumps,
gluteal sets,diaphragmatic breathing exercises,and gentle
activation exercises for both upper and lower extremities.
Chapter 62 · Rehabilitation Following Total Knee Arthroplasty – P. Hernigou, A. Poignard, A. Nogier
Usually, mobility training, dressing, transfers, and ambu- lation are started within 24-48 h after surgery, depending on surgical procedures and patient co-morbidities.
Continuous Passive Motion Protocol
Continuous passive motion was introduced to the ortho- pedic community in 1980 by Salter et al. [20] .The biolog- ical effect of continuous passive motion on the healing of full thickness defects was studied in the rabbit knee articular cartilage. It was found that continuous passive motion was strikingly beneficial. However, the device described was not suitable for clinical practice. In 1982, Coutts et al.[2] introduced continuous passive motion for the postoperative rehabilitation of patients who under- went total knee arthroplasty. Range of motion (ROM) at day 10 was significantly better and the use of pain med- ication was decreased [2]. Following this study, the use of continuous passive motion devices following total knee arthroplasty increased dramatically.
At our institution continuous passive motion is start- ed on the morning of postoperative day 1. The nursing staff places the patient’s extremity onto the continuous passive motion device 1 h per nursing shift (three times per day), beginning at 0°-30° of flexion. This is increased by 10°-20° per day,based on the patient’s level of pain.The patient is also seen by a physical therapist twice a day, be- ginning on the first postoperative day for gait training with a walker or crutches and active assisted ROM of the knee. The patient is usually discharged late afternoon of postoperative day 6. Outpatient physical therapy is con- tinued two to three times a week for the first 3-4 weeks after discharge. The patients are seen approximately 14 days after surgery for suture removal and to check ROM. If a patient has not progressed to at least 70° flex- ion at this time, a manipulation is considered.
The effects of continuous passive motion on the range of motion of the knee remain controversial. The report- ed benefits include decreased need for knee manipula- tion, fewer instances of deep venous thrombosis, de- creased postoperative use of analgesics, and a greater fi- nal range of motion. Reported disadvantages include increased wound complications, bleeding, and pain.
Patients who undergo continuous passive motion tend to have a greater range of motion at the time of discharge, but this advantage appears to lessen during the subse- quent follow-up period.
Alternatives to
In-Hospital Continuous Passive Motion
Alternatives to the use of continuous passive motion de- vices in the hospital have been proposed recently. In a
study by Kumar et al.,46 knees for which continuous pas- sive motion was used were compared with 37 knees treat- ed with an early passive flexion protocol (“drop and dan- gle”) [6]. The latter protocol required that the patient be positioned at the side of the bed or in a chair and the foot of the surgically treated leg was placed on the floor by a therapist. With the foot firmly on the floor, the patient moved his or her body forward until 90° knee flexion was achieved.Patients in whom the drop-and-dangle protocol was used had better extension at 6 months. However, ma- nipulation was required in 9% of the group in whom the drop-and-dangle technique was used versus 2.5% in the group of patients who received continuous passive mo- tion. In another prospective randomized study of 80 pa- tients, use of a continuous passive motion device at home was compared with professional home physical therapy visits after total knee arthroplasty [24]. No difference in ROM or extensor lag at 6 months was observed. The cost of continuous passive motion was approximately half that of home physical therapy.In addition,95% of the patients thought that continuous passive motion use at home was easy and helpful in their rehabilitation.
Manipulation
Manipulation may be necessary after total knee arthro- plasty if early postoperative ROM is not adequate. There may be less ultimate ROM at long-term follow-up in knees that do not obtain a satisfactory ROM in the early postoperative period. In the late 1970s and early 1980s manipulation was reported to be necessary after total knee arthroplasty in as many as 54%-60% of patients [4].
Manipulation has been associated with a high incidence of postoperative heterotopic ossification in the quadri- ceps muscles. Several studies have shown the beneficial effect of continuous passive motion on the rate of ma- nipulation [2, 3, 12, 17, 19, 20]. Coutts et al. [2] reported the results of a multicenter study in 1983: Among patients undergoing total knee arthroplasty, a control group of 129 patients was compared with an experimental group of 137 patients who used constant passive motion. The patients in the continuous passive motion group had no manipulations, whereas 21% of the patients in the control group required manipulation.The indication for manipu- lation was the inability to achieve 90° of active flexion by 6 weeks after surgery. Manipulation under anesthesia is performed less frequently today than it was 20 years ago.
Manipulation rates are now usually below 5% and for
some surgeons below 1%. This change in practice reflects
the fact that motion may improve spontaneously up to
1 year after the surgery and after manipulation patients
may experience complications including hemarthrosis,
quadriceps rupture,periprosthetic fracture,implant loos-
ening, and heterotopic bone formation.
and Blood Loss During Rehabilitation Postoperative Pain Management
After Total Knee Replacement
The management of postoperative pain is a challenge that faces surgeons and patients alike after total knee arthro- plasty. Many surgeons consider total knee arthroplasty to be much more painful than total hip arthroplasty. Effec- tive pain management can improve the ultimate ROM by allowing earlier achievement of greater flexion.
The value of preemptive analgesia with long-acting oral narcotics delivered on a fixed schedule rather than on an “as-needed” basis has been shown to improve pain control substantially. COX-2 inhibitors have also received attention as an adjunctive form of analgesia that may help to decrease postoperative narcotic requirements. Intra- articular anesthetic injections may provide modest im- provements in postoperative pain management for the first few hours following surgery.
Nerve blocks have become increasingly accepted as a form of postoperative pain management.Although the knee is innervated through branches of the femoral, obturator, and sciatic nerves, the individual contributions of each of these nerves to pain patterns after total knee arthroplasty have not been well established.The so-called femoral block in the inguinal region produces a blockade of the femoral, obturator,and lateral femoral cutaneous nerves.Substantial improvements are seen in terms of narcotic use, length of hospital stay, postoperative bleeding, range of motion, and overall complications in patients who receive nerve blocks [6, 7]. Continuous epidural analgesia provides pain relief similar to that with continuous femoral nerve block but is associated with more side effects [6,7].Usually,the femoral nerve block is given either as a single postoperative in- jection or as a continuous postoperative infusion.
Wound Healing
Wound complications may occur more frequently in knees that have early continuous passive motion. Maloney et al.
compared 95 knees that were immobilized for 4-6 days with 51 knees for which continuous passive motion was be- gun in the recovery room [10]. There were major wound complications in 2% of knees that were immobilized com- pared with 12% of knees in which continuous passive mo- tion was begun in the recovery room. The explanation for the increased rate of wound complications after continu- ous passive motion were partially explained by the study of Johnson,in which the transcutaneous oxygen tension of the midpoint of a total knee arthroplasty incision was measured [5]. In this study of 102 patients who had a pri-
edges, particularly the lateral side, for the first 3 days after surgery. Maloney et al. concluded that early vigorous con- tinuous passive motion may increase the chance of skin necrosis or other wound problems [10]. In a randomized study of 54 patients by Nielsen et al., one group received continuous passive motion 4 h/day and the other group received no continuous passive motion [14]. There was no difference in ROM at 14 days after surgery, but there were more wound complications in the group without contin- uous passive motion.
Deep Vein Thrombosis
The effect of continuous passive motion on the prevalence of deep vein thrombosis after total knee arthroplasty is not clear. In a prospective randomized study of 62 patients who had primary total knee arthroplasty and routine venography, Vince et al. reported a positive venogram in 45% of patients treated with continuous passive motion versus 75% of the control group [22]. No patient had thrombophlebitis of the femoral or pelvic veins and the re- sults of all lung scans were negative. In a review of the prevalence of deep vein thrombosis and pulmonary em- bolism after total knee arthroplasty using a wide variety of prophylactic measures, Lynch et al. reported a 71%
prevalence of venographic deep vein thrombosis and a 22% prevalence of pulmonary embolism in a group of 484 patients [9]. In a separate group of 255 patients in whom continuous passive motion was used, the prevalence of deep vein thrombosis was reduced to 20% and the preva- lence of pulmonary embolism was reduced to 6% [15].
These authors concluded that continuous passive motion and pneumatic compression together provided improved prophylaxis against thromboembolism after total knee arthroplasty. However, these data were challenged in an- other prospective randomized study of 150 patients un- dergoing total knee arthroplasty,with one group receiving continuous passive motion and a control group doing ac- tive assisted exercises of the knee [16].All patients received aspirin prophylaxis, 650 mg twice a day, beginning on the day of admission. Forty-five percent of the patients who received continuous passive motion had venographically proven calf vein thromboses, compared with 37% of those patients who did not receive continuous passive motion.
However, this difference was not statistically significant.
No patient had a pulmonary embolism.
Blood Loss After Total Knee Arthroplasty
Continuous passive motion has been reported to in- crease blood loss after total knee arthroplasty.Lotke et al.
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Chapter 62 · Rehabilitation Following Total Knee Arthroplasty – P. Hernigou, A. Poignard, A. Nogier
reported on a prospective randomized study of 121 pa- tients with total knee arthroplasties [7]. The greatest blood loss occurred in patients who had intraoperative release of the tourniquet and continuous passive motion begun in the recovery room. Pope et al. performed a prospective randomized study of 57 knees that were di- vided into three groups [15]. The average blood loss of patients who did not receive continuous passive motion was 956 ml, while patients who received continuous pas- sive motion from 0° to 40° of flexion had a mean blood loss of 1017 ml, and patients who received continuous passive motion from 0° to 70° of flexion had significant- ly more blood loss (mean: 1558 ml). Findings from these studies indicate that continuous passive motion proba- bly should not be started in the recovery room in order to minimize blood loss.
Influence of Prosthesis Design and Operative Technique on Rehabilitation Designs of Knee Prostheses
Designs that increase the quadriceps moment arm may reduce quadriceps tension,facilitate activities of daily liv- ing,and enhance rehabilitation.Mahoney et al.compared patients who had received a posterior cruciate-substitut- ing prosthesis with patients who had received a design that increased the patellofemoral moment arm by 30%
[10].After the operation, more patients who had received the latter design reported no anterior knee pain and were able to rise from a chair without using their arms.Mobile- bearing knee arthroplasty offers the advantages of in- creased conformity and greater mobility, which theoreti- cally translates into improved function and range of motion.
Standard Surgical Approach
The medial parapatellar approach and the midvastus approach are used commonly in total knee arthroplasty.
Patients managed with both operative approaches during bilateral primary total knee arthroplasty required fewer lateral retinacular releases, had less pain at 1 and 6 weeks, and were more likely to be able to perform straight-leg raises earlier on the side managed with the midvastus approach [6].
We have used a surgical technique which was initiat- ed in 1993 that includes incising and closing the knee in flexion. This may allow earlier return of quadriceps strength and range of motion. A concern with this tech- nique was extension lag. However, our experience has demonstrated that muscle strength is not hindered by closing the knee in flexion.
Minimally Invasive Approach
Minimally invasive approaches have been developed re- cently. This term implies that there is less disruption of the anatomical structures about the knee. The minimally invasive approach does not violate the skin, extensor mechanism, or suprapatellar pouch as much as conven- tional approaches do. It may produce less discomfort and a faster recovery.
Patient Expectations at the End of Rehabilitation
Patient-assessed recovery with regard to pain and func- tion after total knee arthroplasty has not been as favor- able as that after total hip arthroplasty, even though the quality-of-life improvements recorded after knee arthro- plasty matched those recorded after hip arthroplasty [23].
A typical “surgically successful”knee arthroplasty may be considered a failure by the patient because the outcome does not match the patient’s expectations. Expectations vary by diagnosis, patient characteristics, and functional status.Regardless of age,patients who have undergone to- tal knee arthroplasty usually do not have comparable overall physical health when matched with the general population for age and gender. In studies comparing functional ability perceived by individuals after total knee arthroplasty with age-matched individuals without knee disability, significantly greater perceived difficulty with walking and stair performance was found in patients with total knee arthroplasty than in controls [6].
The acute care goals are inherently aimed toward hos- pital discharge, which is achieved when the patient is am- bulatory, usually with a walker or cane. This occurs in 5-10 days, and discharge may be to the home, a rehabili- tation unit, or a skilled nursing facility. The transition to the intermediate postoperative phase of rehabilitation occurs after 2-3 weeks and continues for 4-12 weeks. The goals are functional independence in all activities of daily living and return to employment,community activ- ities, and recreational pursuits. Ideally, knee ROM of 0°-5° of extension and 110°-120° of flexion will be ob- tained. Therapeutic exercise should be focused on attain- ing optimal muscle strength and endurance, ambulation over a variety of surfaces and distances, and safe static and dynamic balance.
One of the most difficult problems at the end of the rehabilitation is the stiff knee. Most patients are content if they have 100° of flexion and can rise from a chair and walk up and down stairs. However, patients who cannot flex beyond 90° will be very aware of the limitation. Ma- nipulation can be offered between 45 days and 8 weeks.
However,manipulation beyond 8 weeks may not increase
motion and can risk tendon or ligament avulsion,or frac-
The end stage of total knee arthroplasty postoperative rehabilitation, from 3 to 12 months, is frequently under- emphasized because the patient has had good to excellent pain relief and is walking within 12 weeks. Nevertheless, full physiological and functional recovery usually re- quires longer than 3 months and may never be attained.
Walsh and colleagues compared patients who were 1 year post-total knee arthroplasty with age- and gender- matched controls without knee pathology [23]. Isokinet- ic peak torque measurements were reduced by more than 25% in the female total knee arthroplasty patients and by 35% in the male patients when compared with controls.
The speed of walking and stair climbing was also signifi- cantly lower in the total knee arthroplasty patients.
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