Knee Replacement


Total knee ReplacementDue to the rise in knee joint osteoarthritis, there is a rise in cases of knee replacement surgeries. The knee replacement is also known as knee arthroplasty. It is of two types:

  • Partial Knee Replacement
  • Total Knee Replacement (TKR)

Role of Physiotherapy

Physiotherapist plays an equally important role as the surgeon performing the surgery. This is due to the fact that surgeon replaces a knee joint but the soft tissue i.e. ligaments, muscles, and myofascia requires a tissue- level engineering to gain a pain- free, fully functional knee joint, which will be done by the physiotherapist after the surgery.

When to go for Total Knee Replacement?

The foremost indication to undergo a knee replacement surgery is the pain that is immense and disabling i.e. it is affecting the day to day activities. This pain along with severe arthritic changes evident on radiographs requires a planned knee replacement surgery. But before undergoing knee replacement, the following conservative treatment can be considered:

  • NSAIDs ( Non- steroidal anti- inflammatory drugs)
  • Physiotherapy treatment for at least one month
  • Lifestyle modification and ambulatory aids, for example, cane, leaving cross- legged sitting, use of western commode etc
  • Early surgical intervention – steroid injection, arthroscopic debridement etc as per the consultant surgeon advice.

Outcomes: Knee Replacement

Exercises and sportsAfter an initial period of extensive physiotherapy and rehabilitation (say about 2- 3 months), a person can expect a pain free or nearly pain free knees, a normal pattern of walking that also allows the patient to ascend or descend the stairs (although stair climbing should be restricted after total knee Replacement). Along with this, the person will be able to do all activities of daily living. Cross- legged sitting is generally not advisable (some implants offer that opportunity also).

Post- operatively knee flexion range of 900 should be attained for normal activities of daily living. But 1050 to 1100 of knee flexion range is required f both the patient is going for knee Replacement for both the knees simultaneously. This is the preliminary requirement to rise from a normal heighted, western style toilet seat.

Rehabilitation procedure : Knee Replacement

Early goals of Physiotherapy

  • Following the knee replacement surgery, there must be rapid mobilization of patient to avoid the complication of bed rest i.e. DVT (Deep Vein Thrombosis), Pulmonary Embolism, pressure ulcers or bed sores.
  • 0- 900 of knee ROM (Range of Motion) in the first two weeks of Arthroplasty (except mention by surgeon). Along with this, complete extension should be achieved in the operation room following surgery. And rehabilitation procedures should take care to maintain that range.
  • Rapid return of Quadriceps strength (especially VMO component) and knee musculature strengthening.
  • Learning safe transfers and ambulation
  • Independent walking with an assisted device.

Note: In case of complex knee arthroplasty involving osteotomies or other procedures simultaneously, the patient may be non- weight bearing for a longer duration.

Pre- operative Physiotherapy

Pre- operative Physiotherapy play a very important role in successful outcome of Total Knee Replacement (TKR). 2- 5 Pre- operative Physiotherapy sessions should be undertaken before going for arthroplasty. Benefits of Pre- operative Physiotherapy includes:

  • This will help patient to learn all the exercises that she needs to do following surgery. Learning of exercises will be somewhat difficult after the surgery due to pain, knee stiffness etc.
  • Learn to walk with walker, ascending and descending of stairs with stick and other transfers.
  • Making the patient aware of the overall procedure and initial pain after the surgery that may stay there for few weeks. In many cases, when pre- operative physiotherapy sessions have not considered, it will become for few patient to cope with the pain, difficulty in initiating movements for few weeks following knee replacement surgery.
  • Cold Pack Knee ReplacementLearn to use the cold pack.
  • Precautions that needed to be followed after the surgery. These includes avoiding placement of pillow below the knee while resting, avoid putting excessive load on the replaced knee by trying to walk without walker, unless it is advised.

Post- operative Physiotherapy

First week

This phase of post-operative physiotherapy is generally covered in hospitals and thus no elaborations are required here. Main points include:

  • Maintaining complete extension range
  • Minimizing the effects of bed boundation by early ambulation
  • Minimizing edema in lower limb especially at ankles and knees
  • Minimizing inflammation at knees by use of cold packs
  • Gait training and stair ascending/descending

Note: these points are indicative only and individual protocol should be prepared according to the type of arthroscopy, pre- operative client status, post- operative client status etc.

Early weeks (2nd to 8th week)

This is the most challenging rehabilitation period for the physiotherapist following knee replacement surgery. This is the phase that decides the outcomes of the surgery. In this phase, physiotherapy should be continued at home under the guidance of a well- qualified physiotherapist.

Major goals include:

  • Increasing the flexion range to 900 – 1200 depending upon the requirements, ability of the client and other post- surgical factors.
  • Keeping the post- surgical pain to the minimal level.
  • Helping the client learn the use of western style toilet seat.
  • Rapid increase in strength of quadriceps, hamstrings and gluteal muscles (hip musculature).
  • Post operative scar mobilisationNormal scar mobility
  • All other goals will remain the same as mentioned in the earlier section.

After 8th week

After the completion of two months of extensive rehabilitation and rigorous exercises, it is expected that patient should have minimum pain, no swelling/ redness, minimal scar line. Along with this, the patient should be able to use western style toilet seat, able to walk with stick. After this period patient seldom requires the support of physiotherapist but advised to continue all the exercises and walk on a regular basis throughout the life.

Walking outcomes: It is expected, from most of the patient, that they should be able to walk without stick after 12th week of Total Knee Replacement Surgery. But it is also advised to use the stick throughout the life when moving out of house.