Total knee arthroplasty (TKA) is a proven treatment for many knee pathologies; rehabilitation plays an important role in the recovery of joint function after total knee arthroplasty. Postoperative rehabilitation is a long-term and systematic process. Appropriate rehabilitation not only has a great impact on the outcome of the surgery, but also directly affects the recovery of knee function, so it requires the active cooperation of the patient and the joint between the doctor and the patient.
The purpose of rehabilitation treatment is to prevent the lack of activity of the knee joint fluid can not be effectively circulated after surgery, resulting in local tissue contracture, adhesion and stiffness, prevent the correction of limited joint mobility; restore muscle strength, enhance joint stability, improve joint function, improve the weight-bearing capacity and gait of the lower limbs, and improve the quality of life.
Therefore, functional exercises after knee replacement mainly include knee extension, joint mobility and quadriceps muscle strength exercises, of which the key period for knee extension and joint mobility exercises is 3 months after surgery. The soft tissues around the knee joint are basically fixed from 3 months to 6 months after surgery, and it is difficult to increase the mobility of the knee joint through exercises at this time.
For the first two to three days after knee replacement, the patient is not yet on the ground and can perform foot hooking exercises during this time. By hooking the foot and contracting the muscles, blood circulation can be improved and thrombosis can be prevented. Attention should also be paid to regular turning to prevent decubitus ulcers.
On the first day after surgery, the head of the patient’s bed should be shaken high, help the patient sit up, and encourage the patient to actively spit, especially in patients with general anesthesia of tracheal intubation, a lot of sputum has accumulated in the trachea and lungs, which may cause pulmonary atelectasis and lung infection if not discharged in time.
When the knee joint is locally swollen and painful, infrared light, ultra-short wave, hot compress and other warm therapy, or apply cold therapy, so that the local muscle spasm caused by pain can be relieved, massage, etc. also have similar effects. For patients with severe pain or those who are sensitive to pain, analgesic drugs can be added during exercise.
After the drainage tube is removed two to three days after the operation, the patient should go to the ground as soon as possible, because the blood circulation of the lower limbs will be accelerated after going to the ground, which can well prevent the formation of venous thrombosis. The first time to move to the ground must pay attention to safety, first let the patient sit at the bedside for a period of time, after adaptation, and then stand at the bedside for a period of time with the assistance of a walking frame and the help of nursing staff, if you feel okay, no dizziness and other discomfort, you can try to walk and other activities.
Early postoperative knee activities can prevent postoperative adhesions, shorten the postoperative recovery time, and increase the patient’s confidence in recovery. If the knee joint does not move properly early, it can easily cause fibrosis around the knee joint, and after fibrosis is formed, it is difficult to increase the flexion of the joint. In the past, some patients were reluctant to move due to fear of pain and re-entered the operating room to perform joint thrusting under anesthesia, causing more pain.
After the drainage tube is removed from the artificial knee, the knee can be increased in flexion and extension.
It is advisable to wear loose clothing before knee flexion and extension activities so as not to interfere with the activities, preferably pajama pants; wear shoes with non-slip soles to avoid falls. Mental factors also play a large role in exercise. Patients should try to communicate with their supervisors to get encouragement to maximize their potential, especially those with low muscle strength and limited mobility.
A combination of different forms of exercise combines exercise in an active and passive manner, otherwise even if passive knee mobility has been achieved, if the patient has low muscle strength, then the mobility that has been gained will be partially lost. During postoperative exercise, if the wound has not healed definitively, care must be taken to protect the wound from contamination.
Unless the knee swelling is particularly severe or the wound is exuding, etc., the patient should generally perform flexion and extension exercises with the assistance of a passive knee mobilizer two to three days after surgery when the knee x-ray is clear. At the time of discharge, the patient should have a knee flexion mobility of at least 90°.
Since the function of the knee joint is mainly reflected in joint mobility and muscle strength of the quadriceps and N cord muscles, the main content of postoperative rehabilitation is the exercise of joint mobility and muscle strength of the quadriceps and N cord muscles. In addition, in order to cooperate with walking and recovery of physical strength, physical recovery exercises can be carried out incidentally. The intensity of the initial exercise is limited to the minimum, rather than excessive, it is better to increase gradually in small amounts; increase or decrease the amount of exercise according to the response after exercise and the next day; evenly distribute the amount of exercise, patients should rest at short intervals; adjust the intensity, time and manner of exercise according to the needs of different rehabilitation periods and functional recovery.
Hooked leg lift to exercise muscle strength
Quadriceps exercise is an important exercise for joint replacement patients. When the patient’s vital signs are stable, the patient should adopt a semi-sitting position as early as possible; start active contraction of the quadriceps, triceps and tibialis anterior muscles to accelerate venous reflux and prevent deep vein thrombosis.
Early postoperative quadriceps muscle strength has not yet recovered, it is difficult to complete the leg lifting action, you can first hook foot exercises. With the recovery of muscle strength, a pillow can be placed under the N fossa for the exercise of hooking the foot and lifting the calf; or a bandage can be placed on the foot, and the patient can pull the ends of the bandage with both hands to perform the exercise of hooking the foot and lifting the leg with the assistance of hand strength; or the exercise of hooking the foot and lifting the leg can be performed with the assistance of others tugging the trouser leg. The latter two types of hooked leg lifts are performed with the help of external force when the quadriceps muscle strength is insufficient, and it should be noted that the strength of the legs should be relied on primarily, and external force is only an aid.
The standard hooked leg raise exercise.
One, hook the toes.
Two, stomp the heel, try to straighten the knee joint.
Third, lift the lower limb, the heel is about 20cm from the bed, insist on 5~10 seconds, put it down. Hooked foot leg lift exercise can be performed in multiple groups per day depending on the patient’s condition.
Specific methods are.
1. Ankle dorsiflexion and plantar flexion (hooked foot exercise): active maximum flexion and extension of the ankle joint and resistance training. Hold each movement for 5 seconds and repeat 20 times/group, 2 to 3 groups per day.
2, supine position contraction quadriceps training: do static contraction of quadriceps, hold for 5 seconds each time, each 20 times / group, 2 to 3 groups / day; at the same time the patient can do straight leg raising exercise on the bed, do not require the height of the lift, but to have about 5 seconds of lag time; slowly move the affected limb heel to the hip, so that the hip and knee joint flexion, toe forward, to prevent internal rotation of the hip, the caregiver can hold the affected limb by hand Ankle, assist the patient to hold for 10 seconds, repeat 20 times, do 2 to 3 groups daily.
3, downward pressure on the knee joint: sitting position, leg straight, put a round pillow under the foot, elevate the foot, hanging under the knee, press the knee joint to pull the thigh tendon and calf tendon.
First day after surgery:After removal of plasma drainage tube and urinary catheter, get out of bed and walk with the help of a walker. Learn to get out of bed, go to bed and take steps correctly. Strengthen the muscle strength exercise of both lower limbs. Have confidence in getting out of bed and walking, the more enthusiasm you put into it, the faster you will recover.
Exercises to prevent periarticular adhesions and fibrosis.
The peri-articular area can be fibrotic due to hematoma mechanization, so learn to massage the soft tissue around the joint to loosen and soften it. This exercise can be used throughout the rehabilitation process from the first week after surgery, and can also be used as the first movement of the entire exercise program to loosen the soft tissues around the joint and facilitate the flexion and extension movements of the joint. Method: The root of the palms of both hands are pressed against the skin of the knee joint medially and laterally with a deep circular massage, which can be performed from the lower 1/3 of the femur to the upper 1/3 of the tibia at several different points, without rubbing the skin.
After the incision is healed, another action can be added, namely, two thumbs pressed on the incision at an interval of 1 cm, and then the skin is pulled in the opposite direction 3 to 5 times in the direction of the incision until the entire incision is pulled.
Continuous increase in joint mobility
After total knee arthroplasty, restoration of knee mobility (rangeofmotion) and gait training is the focus of postoperative rehabilitation of total knee arthroplasty and should be followed throughout the rehabilitation process. In principle, it can be performed on the day after the recovery of anesthesia under the premise of effective analgesia, and passive activities should be the main focus within 1 week after surgery, and active activities should be the main focus after 1 week.
The actual mobility of the joint is based on the angle of active knee flexion in the prone position, and on the 7th to 14th postoperative day: the infusion is gradually stopped, and the functional exercise of the knee joint is focused on muscle strength exercise and increasing the joint activity. It is best to have a physician on site to provide guidance.
Exercises for knee mobility during hospitalization are mainly carried out with the assistance of a passive mobility device (CPM). Some rehabilitation centers abroad advocate starting CPM on the first day after surgery, but in China it is still done two to three days after the drainage tube is removed.
In addition to CPM, there are many ways to exercise the knee joint to bend. You can sit on the edge of the bed, let the lower leg drop naturally, and exercise the knee bending with the aid of gravity, while using the opposite heel to press the dorsum of the operated foot to bend the knee; you can also lie on the bed and hold the lower leg with both hands to help the knee bending. If possible, you can practice knee flexion and extension with a static bicycle.
Straighten to walk steadily
Knee straightening exercises are also an important part of rehabilitation exercises. Since the knee joint is straight when the lower limb is walking, it is more important to be able to straighten the knee joint than to be able to bend it. For patients who cannot straighten the knee joint, you can put a thick object on the heel pad to suspend the knee joint and straighten it under the effect of gravity; you can also put a pillow on the knee or help straighten the knee joint under the pressure of others.
Six weeks after surgery, patients with good muscle strength recovery can start to practice climbing stairs. By practicing stair climbing, you can exercise muscle strength on one hand, and joint mobility on the other. It is important to pay attention to “good up and bad down”: when going upstairs, take the good leg first, and when going downstairs, take the surgical leg first, one step in two steps. At the beginning of the exercise, someone should be there to protect you. After 6 weeks post-operatively, the amount of walking activity should be gradually increased to promote the wear and tear of the artificial joint.
Total knee replacement patients still need to use a walker for a considerable period of time after surgery. The walker can effectively improve the stability of the patient’s body and can better share the load, so the use of a walker should be emphasized after surgery; follow the principle of rather slow and accurate, not fast and unstable. When using a single cane or single-axillary crutch, the walker goes first, the affected leg follows, and the healthy leg takes the third step. When using double axillary crutches, the crutches are synchronized with the affected limb and alternate with the healthy side. When going upstairs, the healthy leg goes first, and when going downstairs, the affected leg goes first, thus effectively protecting the knee joint.
In conclusion, the efficacy of knee replacement surgery depends to a large extent on the patient’s adherence to rehabilitation exercises after surgery. Surgery is a joint project between the patient and the surgeon, and if the project is scored out of 100, the surgeon can only get 50 points for a good surgery, and the remaining 50 points need to be obtained by the patient from the post-operative rehabilitation exercises, which means that the other half of the success of the surgery is in the hands of the patient. The patient must be with the doctor in order to get the full score.