Case

presentation
Musculoskeletal
Total Knee Replacement
Presented by : Noor Hanim bt
Ahmad
BJPA2007-6384

KSKB Sg Buloh

INTRODUCTION : anatomy of the knee

Knee is the largest joint in the body. Knee is made up
of femur, tibia and patella.
Large ligament attach to the femur and tibia to provide
stability and strength.
Articular cartilage is a smooth subtance that cushions
the bone and enables them to move easily. Synovial
membrane release special fluid that lubricates the
knee, reduce friction in healthy knee.
Normally all of these components work in harmony but
disease or injury can disrupt this harmony, resulting in
pain, muscle weakness and reduce function.

Picture of the knee

Normal knee

Knee with arthritis

If knee is severely damage by arthritis or injury, it may be

hard to perform simple activities such as walking or
climbing stairs and may begin to feel pain while sitting or
lying down.

Medication, changing activity level and using walking

supporter no longer helpful. By resurfacing the damaged
and worn surfaces of the knee can relieve pain, correct
leg deformity and help resume normal activities.

One of the most important orthopedics surgical advances

of the twentieth century, knee replacement was first
performed in 1968.

Total knee replacement

A total knee replacement (TKR) also call knee arthroplasty
is a surgical procedure of the knee joint is replaced with
artificial material.
During a total knee replacement, the end of the femur is
removed and replaced with a metal. The proximal end of
the tibia is also removed and replaced with a channeled
plastic piece with a metal stem.
The cartilages and the ACL and PCL are remove but the
collateral ligaments are preserved.
This prosthesis allow 90 of knee flexion and full extension.
The aim are to relief pain and improve function.
-Therapeutic Exercise Foundations and Techniques; 4 th edition;
Carolyn Kisner, Lynn Allen Colby.

X ray view

The incision for the knee replacement

Indication
Severe osteoarthritis of the knees.
Gross instability or limitation of motion.
Marked deformity of the knee.
Decreasing daily function lead the patient
to consider total knee replacement.
Failure of a previous procedure.
-Therapeutic Exercise Foundations and Techniques; 4 thedition; Carolyn Kisner, Lynn
Allen Colby.

Contraindications
An open infection in the operative area is generally
regarded as an absolute contra-indication to total
knee replacement.
A source of infection somewhere else on the body
is a relative contra-indication.
Poor general medical status, mental illness or
inability to cooperate with post operative
restrictions

Risks of undergoing a total knee

replacement.
Blood clots in the legs that can travel to the lungs (pulmonary
embolism).
Bleeding into the knee joint.
Nerve damage, blood vessel injury.
Infection of the knee which can require re-operation.
Chronic knee pain and stiffness.
Pulmonary complication.

-Therapeutic Exercise Foundations and Techniques; 4 thedition;

Carolyn Kisner, Lynn Allen Colby.
-http://:Knee_replacement.htm

Home planning during recovery

Safety bars or a secure handrail in

shower or bath
Secure handrails along stairways
A stable chair for early recovery with a
firm seat cushion (and a height of 18 to
20 inches), a firm back, two arms, and a
footstool for intermittent leg elevation
A toilet seat riser with arms support
A stable shower bench or chair for
bathing
Removing all loose carpets and cords
A temporary living space on the same
floor because walking up or down stairs
will be more difficult during early
recovery

Do and don'ts

Post-op rehabilitation
Post-operative hospitalization varies from
one day to seven days on average
depending on the health status of the
patient and the amount of support available
outside the hospital setting. Protected
weight bearing on crutches or a walker is
required until the quadriceps muscle has
healed and recovered its strength.
CPM is commonly used
Patients typically undergo several weeks of
physical therapy to restore motion, strength
and function.

Cont .
Often range of motion to the limits of the prosthesis is
recovered over the first two weeks (the earlier the
better).
At 6 weeks patients have usually progressed to full
weight bearing with a cane.
Complete recovery from the operation involving
return to full normal function may take three months
and some patients notice a gradual improvement
lasting many months longer than that.

Aims of physiotherapy
To relief pain.
To reduce swelling.
To prevent muscle wasting.
To prevent joint stiffness.
-cryotherapy
-Affected leg is elevated.
- Circulatory exs- Ankle pumping.
- On CPM
- Isometric Quads and gluteal
Foot exs is encourage early- active free exs- mobilise up to 90.
Encourage SLR
Ambulation- walking with walking frame/crutches- FWB as tolerated by
patient.
-Therapeutic Exercise Foundations and Techniques; 4thedition; Carolyn
Kisner, Lynn Allen Colby.

Exercise For Knee

Replacement
Exercise 1 : static Quadriceps exercise
- activates the large Quadriceps muscle
- knee straight and tense up the front muscle at
the front of the thigh
- hold few seconds then relax
- do not tense the buttock muscle

Exercise 2 : Inner Range Quads

- support the roll of pillow under knee as high enough
to lift up the heel of the ground
- straighten the knee as static quads.
- hold few seconds then relax

Exercise 3 : Straight Leg Raise

- sit or lie with leg out straight
- tighten the thigh muscle, straighten the knee and
live the leg 15 cm up off the bed or floor .
- keep the knee straight
- hold 3 seconds then lower slowly

Exercise 4 : Knee bends on the bed

- slide the foot towards the body, bending the
knee.
- holds it at the full bends for 3 seconds.

Case
presentation
of TKR

Case study : 1st visit

Subjective
Name : MRs XY
Age

: 64 y/o

R/N

: AS*****

Sex

: Female

Ward : 7A
Date of admitted

: 4th February 2010

Date of assessment : 8th February 2010

DR

: bilateral knee Osteoarthritis

DR Mx : planned for right TKR on 9th February 2010

: refer Physio for pre op management

Pt problem :

1) Rt TKR planned on 9th June 2009 however

cancelled d/t Rt hand cellulitis

2) Pt c/o pain of Rt knee during prolong

standing and walking

Pain scale : 1

4 55

77 8

: 5/10 during walking

: 5/10 during standing
:7/10 during long distance walk
Area : Rt knee joint
Nature : sharp pain & pulling pain
24 hours : no specific time describe
Aggravating factor : long distance walk
Ease :1/10 with pain killer
Irritability : medium

10

General Health : Good

Medical Hx : Hypertension 10+ years on medication
Past medical Hx / surgery : TKR for Lt knee joint done on 21st Oct 2008
Social Hx : live with husband
House : single storey house
Toilet : squatting & sitting toilet
Praying : on chair
Ix / MRI / X ray : Rt AP, lateral and skylines view
Result : ostophytes over the Rt tibia and femur noted.

XRAY

Medication : cont. own medication

T - Nifedipine 10 mg bd : calcium channel blocker to treat HPT ,
Raynauds disease

T Peridopril 4 mg od : to improve blood presure control

T Prazosin 2mg tds : sympatholytic drug used to treat HPT

Occupation : Housewife
Recreation : Housework
Splinting: NIL

Current Hx : Rt knee OA in planning for Rt

TKR on 9th
February 2010
Past Hx :
1) Lt TKR was done on 21st Oct 2008
2) Rt TKR planned on 9th June 2009 was
cancelled d/t Rt hand cellulitis

Observation
General : big size Malay women sitting on bed
: pt conscious
: pt cooperate
Local : flabby thigh
: small feet
: healing scar at Lt knee Jt
: redness skin colour
: no muscle wasting noted
Palpation : crepitous on patella glide
: no warmth around Rt knee joint

Measurement : Range Of Motion

Joint /
movement
Hip

AROM

PROM

Rt

Lt

Rt

Lt

Flexion

AFROM

AFROM

Extension

AFROM

AFROM

Med. Rotation

AFROM

AFROM

Lat. Rotation

AFROM

AFROM

Flexion

0 - 95

0 -110

0 - 100 ERP

0 - 110

Extension

AFROM

AFROM

Dorsiflexion

AFROM

AFROM

Plantarflexion

AFROM

AFROM

Int. Rotation

AFROM

AFROM

Ext. Rotation

AFROM

AFROM

Knee

Ankle

Interpretation : limited ROM of Rt knee flexion d/t pain.

Knee circumference
Right

Left

45cm

43 cm

Interpretation : Rt knee swelling d/t poor circulation

Above base of
patella

Right

Left

5 cm

51 cm

51 cm

10 cm

59 cm

59 cm

15cm

69 cm

69 cm

Interpretation : No muscle wasting noted

Difference

Muscle power
Joint

Muscle

Right

Left

Hip

Flexors

5/5

5/5

Extensor

5/5

5/5

Abductors

5/5

5/5

Adductors

5/5

5/5

Flexors

3/5 within the

existing range

5/5

Extensors

3/5 within the

existing range

5/5

Dorsiflexors

5/5

5/5

Plantarflexors

5/5

5/5

Invertors

5/5

5/5

Evertors

5/5

5/5

Knee

Ankle

Interpretation : reduce muscle power of Rt knee flexors and extensors

d/t pain

Functional Activity
Bed mobility
Roll side to side good
Side lying to sitting good
Sitting to standing good with pain
Prolong sitting with pain
Standing good with pain
Walking fair (limping gait)

Interpretation : reduce functional activity d/t pain

Special test of Rt knee

patella grind test : +ve (pt claims pain at anterior
aspect of patellar)

Sensation test :
Sharp and blunt intact
Hot and cold unable to test d/t no proper equipment in
ward

Problem listing

Pain at anterior aspect of Rt knee due to degenerative changes.

Limited ROM at Rt Knee due to pain.
Reduce muscle strength at Rt knee due to pain.
Reduce functional activity due to pain.
Swelling at Rt knee joint d/t poor circulation

Short term goal

- To reduce pain within 3/7
- To reduce swelling within 3/7
- To increase ROM 1/52
- To improve muscle power within 3/7

Long term goal

- To regain the optimal functional activity of daily living within 1/12

Plan of treatment

Pre-op management
- pain relief
- Therapeutic exs
- Pt education
- Chest PT

S
O

same as initial assessment

A
P

Intervention
Therapeutic Exs
- Static Quad in ly for Rt leg. ( 10 sec. hold, 20 rep,3 times daily)

-SLR for Rt leg.

- ly; Hip. flex.and K. ext. (10 sec.hold 20 rep,3 times daily)

-High sitt; K. ext. (10 sec. hold 20 rep,3 times daily)

Pt. education.

- Advice pt to do the exs as taught.

Pre op chest physio.

- Deep breathing exs. (3rep, 3 cycle / session, 5 session/daily)

- Thoracic expansion exs. Emphasize at lateral costal.

(3rep, 3 cycle / session, 5 session/daily)

- Thoracic mobility exs.

ly; A. raising w. inspiration and A. lowering w. expiration (5 rep, 3x
daily)

- ly; Sh. Circling clockwise and anticlockwise. (5 rep 3x daily )

- Ankle pumping: ly, Ank. Dorsiflex. and plantarflex. (support leg with 2
pillow) (10 times every hour)
-Static gluteal. ( 10 sec. hold, 20 rep,3 times daily)
Evaluation
- Pt able to cooperate and do the exs as taught.
Reassess
- review pt. for the next visit.

th

February 2010

Pt went to the
operation theater for
right TKR

Progression note : POD 1 on 10th February 2010

S : pt c/o pain at the operation site 7/10 VAS

: pt c/o swelling at Rt leg and ankle
: pt claim able to cough effectively and no sputum produce

O : pt supine lying on bed

: Radivac drainage inserted at Rt knee (280 ml amount of blood
collected)
: pt on bandaging around Rt knee joint
: IV drip on Lt hand 500cc
: pt on PCA at Rt hand
: swelling noted at Rt ankle and calf muscle

Vital sign : time taken on 8.40 a.m

Temp : 37C

Temp : 37C

RR : 19 breath/m RR : 12 20 breath/m
PR : 83 beat/m

PR :75 85 beat/m

BP : 113/60 mmHg

range

BP : 120/80 mmHg

Interpretation :

1) Pt afebrile
2) Pt doesnt have SOB
3) Pt having low blood pressure

normal

Auscultation : lungs clear

: a/e equal
Medication : cont. own medication
T - Nifedipine 10 mg bd : calcium channel blocker to treat
HPT , Raynauds disease
T Peridopril 4 mg od : to improve blood presure control
T Prazosin 2mg tds : sympatholytic drug used to treat HPT

X ray view
Implant of concellous screw 3.5 mm x 18mm inserted at the
medial aspect of Rt tibia during operation

Muscle bulk measurement

Marking point above lateral
malleolus

Right

Left

Differen
t

5cm

24cm

22cm

2cm

10cm

26cm

24cm

2cm

15cm

34cm

29cm

5cm

20cm

40cm

34cm

6cm

Interpretation : Rt lower leg around calf muscle swelling d/t

poor circulation
Above base of
patella

Right

Left

Difference

5 cm

51 cm

10 cm

59 cm

15cm

69 cm

Interpretation : unable to measure d/t Rt thigh and knee jt

covered with
bandage

Foot circumference
Right

Left

Different

24cm

22cm

2cm

Interpretation : Rt foot swelling d/t poor circulation

Range of motion
Joint /
movement

AROM

PROM

AROM

PROM

Rt

Rt

Lt

Lt

Flexion

AFROM

AFROM

Extension

AFROM

AFROM

Med. Rotation

AFROM

AFROM

Lat. Rotation

AFROM

AFROM

Flexion

0 - 110

Extension

AFROM

Dorsiflexion

AFROM

AFROM

Plantarflexion

AFROM

AFROM

Int. Rotation

AFROM

AFROM

Ext. Rotation

AFROM

AFROM

Hip

Knee

Ankle

Interpretation : unable to measure Rt knee motion d/t pain +

covered with bandage

Muscle power
Muscle power of Rt knee extensor and flexor unable to
measure d/t : pain
: POD 1 TKR
Knee circumference
Unable to measure d/t Rt knee Jt covered with bandage

Functional activity
Bed mobility
Roll side to side fair d/t pain

no c/o dizziness or nousea

Side lying to sitting fair d/t pain

Sitting to standing not done d/t pain
Hand grip good

A : reduce functional activity d/t pain

: pain at the Rt knee jt d/t post operation for TKR.
:swelling at Rt lower leg d/t poor blood
circulation
P : Pain relief.
: Therapeutic Exs.
: Chest physio.
: Pt. education

I :Therapeutic Exercise
Active free exercise for upper limb 20 rep, 3 times daily
Ankle pumping : ly, Ank. Dorsiflex. and plantarflex.
(support leg with 2 pillow) (15 times every hour)
Static Quad : in ly for both leg. ( 5 sec. hold,
15rep,3 times daily)
Static gluteals :( 10 sec. hold, 30 rep,3 times daily)
SLR for Lf leg : ly; Hip. flex.and K. ext. (5 sec.hold 10
rep,3 times daily)
High sitt; K. ext. & K.flex. (5 sec. hold 20 rep,3 times
daily)

Chest physio :
- Deep breathing exs. (3x, 3 cycle / session, 5 session/daily)
- Thoracic expansion exs.
(3x, 3 cycle / session, 5 session/daily)
- Thoracic mobility exs.
ly; A. raising w. inspiration and A. lowering w. expiration
(7 rep, 3x daily)
- ly; Sh. Circling clockwise and anticlockwise. (7 rep 3x
daily)

Pt. education
-Advice pt to do the exs regularly.
-Advice pt. to avoid activities that place excessive
stress on the knee. These activities include: tennis,
badminton, contact sports (such as football, baseball),
squash, jumping, or jogging.
-Advice pt. to avoid heavy lifting (more than 40 lb) or
weight lifting.
- Advice pt. to avoid sit in kneel sitting, cross sitting
and squad.

E: Pt able to cooperate and to do the exs as taught.

R : Review pt. for the next visit.

: KIV pain relief with cryotherapy
: KIV ambulate pt with walking frame

Progression note : POD 7 on 16th February 2010

S : pt c/o swelling at Rt knee Jt
: pt claim pain at the operation site reduce 2/10 VAS
: pt claim swelling at Rt lower leg and ankle reduce

O : pt sitting on bed
: suture at operation site of Rt knee
: swelling around Rt knee joint noted
: warmth on palpation at Rt knee jt
: redness in skin colour at the operation site

Vital sign : time taken on 8.40 a.m

Temp : 37C

Temp : 37C

RR : 20 breath/m RR : 12 20 breath/m
PR : 85 beat/m

PR :75 85 beat/m

BP : 125/79mmHg

1) Pt afebrile
2) Pt doesnt have SOB
3) Normal blood pressure

Suture site :17 cm

range

BP : 120/80 mmHg

Interpretation :

normal

Muscle bulk measurement

Marking point above lateral
malleolus

Right

Left

Differen
t

5cm

22.2cm

22cm

0.2cm

10cm

24cm

24cm

0 cm

15cm

31cm

29cm

2cm

20cm

36cm

34cm

2cm

Interpretation: mild swelling at Rt calf muscle d/t poor

circulation
Above base of
Right
Left
Difference
patella
5 cm

51cm

51 cm

10 cm

59cm

59 cm

15cm

69cm

69 cm

Interpretation : no swelling at Rt thigh

Feet circumference
Right

Left

Different

22cm

22cm

0cm

Interpretation : no swelling around foot

Knee circumference
Right

Left

Different

48cm

43cm

5cm

Interpretation : swelling around Rt knee jt d/t inflammation on the

operation site

Range of motion
Joint /
movement

AROM

PROM

AROM

PROM

Rt

Rt

Lt

Lt

Flexion

AFROM

AFROM

Extension

AFROM

AFROM

Med. Rotation

AFROM

AFROM

Lat. Rotation

AFROM

AFROM

Hip

Knee
Flexion

10-90

10-95 ERP

0 - 110

Extension

10 lag

PFROM with
ERP

AFROM

Dorsiflexion

AFROM

AFROM

Plantarflexion

AFROM

AFROM

Int. Rotation

AFROM

AFROM

Ext. Rotation

AFROM

AFROM

Ankle

Interpretation : Rt knee flexion and extension limited d/t muscle weakness

+ pain

Muscle power
Joint

Muscle

Right

Left

Hip

Flexors

5/5

5/5

Extensor

5/5

5/5

Abductors

5/5

5/5

Adductors

5/5

5/5

Flexors

1/5

5/5

Extensors

1/5

5/5

Dorsiflexors

5/5

5/5

Plantarflexors

5/5

5/5

Invertors

5/5

5/5

Evertors

5/5

5/5

Knee

Ankle

Interpretation : reduces muscle power of Rt knee d/t pain

Functional Activity
Bed mobility
Roll side to side good
Side lying to sitting good

no c/o dizzy

Sitting to standing fair d/t pain or nausea

Standing fair d/t pain

Walking with walking frame fair d/t pain

Interpretation : reduce functional activity d/t pain

A : reduce functional activity d/t pain

: pain at the Rt knee jt d/t post operation for TKR.
:swelling at Rt knee jt d/t inflammation on the operation site
& poor circulation

P : Pain relief.
: Therapeutic Exs.
: Ambulation
: Pt. education

Intervention
Therapeutic Exercise
Active free exercise for upper limb : 30 rep, 3 times daily
Ankle pumping : ly, Ank. Dorsiflex. and plantarflex. (support leg with 2 pillow) (15
times every hour)
Static Quad : in ly for both leg. ( 10 sec. hold, 20rep,3 times daily)
Static gluteals :( 10 sec. hold, 30 rep,3 times daily)
SLR for both leg : ly; Hip. flex.and K. ext. (10 sec.hold 20 rep,3 times daily)
High sitt; K. ext. & K.flex. (10 sec. hold 20 rep,3 times daily)

Ambulation using walking frame + education

Pt. education
- Advice pt to do the exs regularly.
- Advice pt to apply ice on Rt knee to reduce pain
- Advice pt. to avoid heavy lifting (more than 40 lb) or
weight lifting.
- Advice pt. to avoid sit in kneel sitting, cross sitting
and squad.

E: Pt able to cooperate and to do the exs as taught.

: pt able to walk using walking frame

R : Review pt. for the next visit.

Conclusion
Knee replacement is a very successful operation for knee pain
and disability, with some of the greatest improvements in
quality of life of all medical interventions.
Knee replacement needs the patient to participate fully in the
rehabilitation process. Once the operation has been done the
work has only just begun.
Exercising the main muscle groups around the knee is very
important both before and after having a total knee
replacement. Patient should work closely with physiotherapist to
set the exercise programe before the patient discharge.
Exercise regularly, for instance for 10 minutes 6-8 times a day.
Do not spend all of time exercising or the knee may become
inflamed, swollen and painful.
It needs a mixture of rest and regular exercise, which will be
uncomfortable.

References
Therapeutic Exercise Foundations and
Techniques; 4th edition; Carolyn Kisner,
Lynn Allen Colby.
http://en.wikipedia.org/wiki/Knee_replace
ment
http://:Knee_replacement.htm.

THANK
YOU