Total knee arthroplasty (TKA) is an operation with a very precise efficacy and a postoperative excellent rate of >90%, but the success of the operation can not be achieved without postoperative rehabilitation training. Through clinical practice, we have developed a rehabilitation training program after artificial total knee arthroplasty. The aim is to restore the patient’s limb function and self-care ability through early rehabilitation training. Deng Yue, Department of Orthopedics, Xi’an Aerospace General Hospital.
The methods are mainly preoperative guidance and postoperative rehabilitation training.
1.Pre-operative guidance
First of all, the static contraction exercises of the quadriceps muscle of the affected limb and the active movement of the ankle joint should be strengthened, requiring the quadriceps muscle to remain contracted for 10 seconds each time, and every 10 times for one group, completing 5 to 10 groups per day.
The patient should sit on the bed and perform straight leg raising exercises and ankle joint resistance flexion and extension exercises, the number of times can be determined according to the patient’s condition and repeated 2 to 3 times a day.
In addition, patients should be taught how to use crutches to prepare for walking with a cane after surgery.
2.Postoperative rehabilitation training
2.1.1st week after surgery
The purpose of this period is to reduce the patient’s symptoms, promote wound healing, prevent muscle atrophy, improve joint range of motion, and increase muscle strength.
2.1.1 On the day of surgery, maintain the functional position of the joint, fix the knee joint with a plaster pallet, and keep the foot high and hip low position.
2.1.2 On the second to seventh postoperative day, the affected limb did static contraction of the quadriceps muscle, holding it for 10 seconds each time, and every 10 times was one group, 10 groups per day.
2, 1, 3 The patient sits on the bed and does straight leg raising exercise on the affected limb, without requiring the lifting height, but with a lag time of about 10 seconds.
2, 1, 4 Do dorsiflexion of the affected ankle joint, keeping that joint at 90°, and do the circumferential movement of that joint repeated 15 times, completing 2 to 3 times a day.
2,1,5 Apply continuous passivemotion (CPM) machine to give passive motion of the affected limb in a painless state, with a starting angle of 0° and a termination angle of 20°, completing a round trip within 2 min, 4 hours per day, reaching or approaching 90° as much as possible within 1 week.
2, 1, 6 Use low-frequency modulated medium-frequency current to act on the affected limb twice a day, with current density not exceeding 0, 3mA/cm2 to improve local blood circulation and promote wound healing.
2.2.2nd postoperative week
Focus on strengthening the active movement of the affected limb under non-weight-bearing condition and improving the active range of motion of the joint.
2, 2, 1 Using Maitland maneuver level I, the affected knee is loosened by a small rhythmic back and forth movement of the joint from the starting end of the joint movement within the pain-free range.
2,2,2 The patient sits on the bed with the hip as the fixed point and a slide board is placed under the affected foot and used as the moving point to complete 2,2,1 autonomously.
2,2,3 To further strengthen the straight leg raising movement of the affected limb, a pulley can be fixed above the bed, with one end of the sling holding the affected ankle joint and the other end controlled by the patient to complete the straight leg raising movement through assisted movement, requiring the patient to raise the affected limb as high as possible and maintain the height, and gradually reduce the help of the hand to transition to the active completion of this movement.
2,2,4 Encourage the patient to get out of bed. In the first half of the week, the patient practiced standing in the parallel bar under the action of the plaster pallet, at this time, the center of gravity was on the healthy side, and the affected side was not weighted to touch the ground; in the second half of the week, the center of gravity gradually transitioned to the affected side until the plaster pallet was released and the patient stood upright in the parallel bar.
2.2.5CPM machine use angle increased to 90°～100°.
2, 3, 3rd postoperative week
Continue the active straight leg raising exercise to consolidate the previous training effect, restore the weight-bearing ability of the affected limb, strengthen the walking gait training, train the patient’s balance ability and further improve the joint range of motion.
2.3.1 After the plaster pallet is released, in order to understand the patient’s balance ability, the patient can be allowed to stand and the therapist can push the patient back and forth, and pay attention to whether the patient can maintain his or her own balance.
2.3.2 Patients use crutches to practice walking, and when they are mentally and physically able to do so, they are removed from the crutches and walk in the parallel bars.
2, 3, 3Patients lying on their side with the affected limb on top, straighten the knee joint to do abduction movement, ankle joint at 90°, on the basis of this do back and forth swing exercise, therapist in the opposite direction of the application of resistance, patients need to overcome resistance.
2, 3, 4Maitland maneuver level IV.
2, 3, 5 Prone position with active flexion of the affected knee, or the therapist can help with this.
2,3,6 Bending the knee joint under the action of the quadriceps trainer, starting from 90° with a weight of 1 kg, twice a day for 15 min.
2,3,7 Walking training on a treadmill with the patient looking forward with head up and chest out, no hip cocking.
2,3,8 Pedaling was performed on a stationary bicycle with the cushion starting from the highest.
2,3,9 Patients try to complete daily living actions such as putting on pants and socks independently during this week.
2,4 Postoperative week 4 to 3 months
Focus on further enhancing the results of the 3rd week, increasing the range of motion and weight-bearing ability of the affected limb, as well as the ability to take care of themselves.
2,4,1 Walk independently on mildly inclined slopes.
2,4,2 Independently put on shoes, socks, pants and other activities of daily living.
2,4,3 In addition to functional training of bending the knee, attention should be paid to functional training of knee extension, such as leg press in sitting position.
2, 4, 4 To go up and down stairs, early on, mainly rely on crutches to go up and down, with the healthy leg supporting and the affected limb bearing weight below to partially bearing weight, requiring the healthy leg to go up first and the affected leg to go down first, and then disengage from the crutches after the patient has adapted.
3.Cautions
①When using low-frequency modulated medium-frequency current to act on the affected limb, the therapeutic electric current should not be the tolerated amount, and the standard of 0,3mA/cm2 should be strictly followed to avoid tissue damage.
②Prevent infection after surgery and apply antibiotics systemically or locally.
③Inquire about the patient’s condition and local discomfort before daily training to understand the size of the exercise volume, and pay attention to the results of the floating patellar test, if the floating patellar test is positive, then draw fluid to reduce pressure.
④The training volume should be small to large and progressive, so as not to cause discomfort in the affected knee.
The above is the training procedure we have developed after total knee arthroplasty. After the patient goes home, he or she should also adhere to the training as described above and contact the rehabilitation doctor and the surgeon for regular checkups to assess the function of the affected knee. The patient should train as required, gradually and regularly, so that he or she can recover and return to work as soon as possible.
Whether at home or in a rehabilitation facility, it is important to protect the new joint. Practice those movements that will increase strength and range of motion. For the best recovery, you should avoid risky movements and return to the hospital for regular review. Return to activity slowly; a little stiffness in the knee joint is normal at the beginning.
Increase muscle strength
Stronger leg muscles reduce the forces on the knee joint, which can sustain the joint for longer.
Quadriceps exercises
The easiest and simplest way to do this is to practice straight leg raises. Hook your toes back hard, bounce the muscles in front of your thighs and calves, bounce your knees straight, lift your thighs slowly off the bed, then lower them slowly, and so on.
Increase joint movement
Seated knee flexion exercises
It can make the new joint flexion more smooth. Follow the learned movements to practice knee flexion and extension.
1. Sit in a chair and place a towel under the new joint.
2. Extend your leg as straight as possible and maintain the movement to a count of 5.
3. Then bend the knee joint as much as possible and maintain the movement for a count of 5.
4. Keep repeating.
Review
A post-operative review allows the surgeon to determine how well the joint is healing. The incision sutures are usually removed 2 weeks after surgery.
Go to the hospital for examination when there are symptoms of.
1. increased pain in the knee joint.
2. pain or swelling in the lower leg or thigh.
3. unusual redness, heat or pus flowing from the incision site
4. difficulty breathing or chest pain.
5. Fever over 38℃.
Avoid dangerous activities
Some activities can increase the pressure on the new joint and thus make the prosthesis wear faster. Care should be taken to protect the new joint: do not twist the knee joint, and do not perform high-intensity activities such as running, jumping, race walking or playing basketball when turning but not moving the foot. To avoid twisting the knee joint, you should move your foot first and then turn around
Recovery activities
Practice walking daily to increase strength. Gradually increase your activity level each week. You can drive or return to office work one month after surgery. If the work is more intense, you will need to take 3-4 months off before working. Total knee replacement is a larger surgery, so it takes several months to truly recover.
Post-operative physical therapy and rehabilitation have a tremendous impact on the outcome of a total knee replacement. First, local compression wraps and the use of a knee brake can reduce pain and decrease post-operative bleeding. Ice packs can also be used.
Postoperative exercises for joint range of motion should be performed with or without the use of a CPM machine. Many studies have shown that CPM helps restore knee flexion more quickly and can shorten the length of hospital stay. CPM has not been shown to have an effect on DVT incidence, distant knee range of motion, or knee function scores.
Place pillows under the patient’s feet while in bed to encourage passive extension of the knee. Swinging the lower leg suspended over the bedside can promote knee flexion. Introduce the patient to home functional exercises. Many surgeons have physical therapists introduce patients to functional exercises preoperatively, as postoperative pain and anesthetics can prevent patients from understanding the necessary rehabilitative therapies.
In addition to range-of-motion exercises, postoperative rehabilitation includes strengthening the lower extremity muscles (with an emphasis on the quadriceps), performing gait training (weight bearing to the extent allowed by knee surgery), and guiding the patient through the basic activities of daily living.