Total Knee Replacement

Total Knee Replacement due to Osteoarthritis – knee_osteoarthritisQuite a young one!

History

A 54-year-old recently retired firefighter attended for treatment, assessment and advice regarding his long-standing knee pain.

In the past, he had undergone multiple knee joint injections and arthroscopic (Keyhole) surgery to repair torn menisci (cartilage) in both knees.

He had seen many physiotherapists over the years and essentially felt that until recently he was managing his symptoms independently. He has no other medical issues other than mild hypertension and he runs a Karate club, training up to 4 times per week.

Over the preceding year, his functional ability had declined to have an impact on his daily life and sport. He wanted to enjoy his recent retirement with his wife and grandchildren.

His most recent visit to an Orthopaedic surgeon had concluded that he was finally ‘old enough’ to undergo a Total Knee Replacement.

Ref.1 describes research that shows that a TKR ‘resulted in greater pain relief and functional improvement after 12 months than did nonsurgical treatment alone.’

Ref 2 NHS guidelines on the 108,713 knee replacements in the UK in 2016 state that you will be offered a knee replacement if:

  1. You have severe pain, swelling and stiffness in your knee joint and your mobility is reduced
  2. Your knee pain is so severe that it interferes with your quality of life and sleep
  3. Everyday tasks, such as shopping or getting out of the bath, are difficult or impossible
  4. You’re feeling depressed because of the pain and lack of mobility
  5. You can’t work or have a normal social life

SUBJECTIVE for our patient

  • A constant nagging pain deep in the left knee.
  • Was taking the maximum dose of Ibuprofen and paracetamol.
  • Occasional giving way and a feeling of ‘instability’…”I don’t trust it”.
  • Regular swelling around the knee after activity.
  • Disturbed sleep.
  • Unable to walk further than 100 yards without pain/limp.
  • He was now unable to demonstrate/carryout any Karate moves and kneeling was painful.
  • Morning stiffness and difficulty descending stairs.
  • He absolutely did not want to use a walking stick

OBJECTIVE for our patient

  • Altered gait (walking) pattern with a reduction in weight-bearing over the left knee
  • Standing on a slightly flexed left knee
  • Swelling and joint line thickening – ‘Arthritic Looking Joint’
  • Wasting of the quadriceps muscle
  • Poor balance and Proprioception
  • The range of motion restricted to no more than 100 degrees of flexion without pain
  • Crepitus (noisy) knee joint and patella-femoral joint (knee cap) with flexion
  • Reduced muscle strength in the left leg
  • Poor core stability
  • Pain on palpation along the knee joint line
  • Positive special test for meniscal damage

IMPRESSION

Moderate to severe Osteoarthritis in the left knee with likely underlying meniscal damage/degenerative change.

For more specifics regarding an arthritic joint – see Pasky’s “wear and tear” case study.

 TREATMENT

Pre-habilitation x 3 sessions over a period of 6 weeks

  • Re-iteration of appropriate footwear, basic diet, joint supplement advice
  • Ice therapy regularly, not just after exercises.
  • Gentle Cycling using a static cycle.
  • Hydrotherapy (pool based) exercises
  • Manual therapy including soft tissue massage, trigger point release around the quadriceps and back of the knee.
  • Basic balance and proprioception exercises

* Nb. All within the patient’s pain tolerance levels

We also discussed what was likely to happen when in hospital, checked he was ok with his basic quads exercises as the hospital physio would be around quite soon after surgery to start mobilisation! We practised the use of elbow crutches both on the flat and also up and down stairs.Picture1

Postoperative – 2 weeks after surgery. Weekly appts for the first 3 weeks

  • Checked post-op exercises and progressed as pain allowed
  • Scar tissue management; soft tissue massage and taught patient to manage this independently
  • Gait (walking) re-education, progressing from using 2 walking sticks to one then none within 4-week post op.
  • Lower limb strengthening exercises, core stability exercises and stretches

By 2 months post-op, he was swimming regularly and needed no further physiotherapy input.

By 3 months post-op, he was walking up to 3 miles

By 6 months post-op, he was cycling past 6 miles

By 12 months post-op, he had forgotten about his ‘new’ knee !!

Thoughts

The prospect of a Total Knee Replacement surgery is scary but talking it through with and having treatment from your physiotherapist can allay fears, provide clever hints and tips and even make you stronger to maximize and improve the speed of your recovery. The results are excellent in most cases. – See ref 3.

Keith Allen Shirtcliffe

Ref 1 Total knee replacement outcomes

Ref 2 NHS guidelines on total knee replacement

Ref 3 Total knee replacement is highly effective for pain and function