Osteoarthritis is the most common and disabling joint condition in the world, occurring significantly more for each decade of life that passes and being almost universal in old people. OA develops in many joints but large joint OA typically affects the knees and the hips, causing problems with mobility and independence. As the degenerative process proceeds the joint surfaces become roughened and cause loss of motion, crepitus, pain and loss of muscle strength. Conservative measures are painkillers, a stick, physiotherapy and weight loss, and once these are exhausted then knee replacement is likely.
Medical technology developed in the late twentieth century to the stage that joint replacement has become a common and predictable treatment for severely arthritic joints, proving to give the highest quality of life of all medical interventions. Total knee replacement is now a predictable and very successful intervention with good ten year results and beyond. Knee replacement is becoming a more popular operation than hip replacement and as western populations get older the demand will increase.
The total knee replacement operation replaces the diseased surfaces of the knee with metal or plastic parts. In the case of the knee there are typically four parts:
The femoral component, made of metal, which replaces the knuckle-shaped end of the thigh bone.
Tibial component. Again a steel alloy part and replaces the damaged tibial surface.
The joint insert, made of high density plastic, which sits between the tibial and femoral components.
The patellar button is also of plastic and placed on the back of the kneecap to replace that surface.
The components are fixed in place using cement which acts as a grouting material rather than sticking anything.
Knee replacement surgery causes weakness of the knee muscles, pain, inflammation and joint swelling, all important problems which the physiotherapist needs to treat promptly. Physios in hospitals often use Cryocuffs to provide cold therapy and compression which reduce the knee effusion and the post-operative pain. Analgesia is encouraged regularly and the physio teaches muscle activation of the quadriceps and knee flexion hourly to get the joint moving. Restoring the muscle control of the knee and gaining joint range of movement is the initial goal of the first few day of therapy.
Next the physiotherapist assesses the patient for suitability for their first mobilisation, checking the operation note, the patient's medical observations and the condition of the legs themselves. The operated knee has to have enough stability to safely weight bear, as an epidural can cause profound loss of muscle power and prevent safe mobilisation until the drugs wear off. The patient is mobilised into standing by the physio with an assistant and encouraged to walk a small distance with elbow crutches or a Zimmer frame for more elderly persons. Operative protocol usually encourages normal weight bearing through the new knee as this helps restore normal patterns of muscular activity and improves circulation.
After discharge the physiotherapist will work on increasing joint range of motion, improving functional skills and improving muscular power and control of the knee. Typical exercises include knee flexion exercises to increase movement, inner range quadriceps for quads strength into extension and knee hangs to increase extension. Resisted work to the hamstrings uses reciprocal inhibition, the technique whereby working one muscle relaxes the antagonists, in this case increasing knee bend. Physios can do this manually or use resistance bands and encourage soft tissue massage to the scar to mobilise the tissue.
After individual work patients move on to gym based work, often in groups, to continue with strengthening muscles using gym balls or resisted rubber bands and dynamic activities such as standing up/sitting down and step-ups. Static bicycling and resisted exercises can be used to increase flexion further and training in joint position sense or proprioception is added. Proprioception is the ability of the joint to sense where it is in space, how fast it is moving and with what force, and is trained by balancing on a wobble board. Gait patterns are corrected and the physio teaches a normal pattern.
Medical technology developed in the late twentieth century to the stage that joint replacement has become a common and predictable treatment for severely arthritic joints, proving to give the highest quality of life of all medical interventions. Total knee replacement is now a predictable and very successful intervention with good ten year results and beyond. Knee replacement is becoming a more popular operation than hip replacement and as western populations get older the demand will increase.
The total knee replacement operation replaces the diseased surfaces of the knee with metal or plastic parts. In the case of the knee there are typically four parts:
The femoral component, made of metal, which replaces the knuckle-shaped end of the thigh bone.
Tibial component. Again a steel alloy part and replaces the damaged tibial surface.
The joint insert, made of high density plastic, which sits between the tibial and femoral components.
The patellar button is also of plastic and placed on the back of the kneecap to replace that surface.
The components are fixed in place using cement which acts as a grouting material rather than sticking anything.
Knee replacement surgery causes weakness of the knee muscles, pain, inflammation and joint swelling, all important problems which the physiotherapist needs to treat promptly. Physios in hospitals often use Cryocuffs to provide cold therapy and compression which reduce the knee effusion and the post-operative pain. Analgesia is encouraged regularly and the physio teaches muscle activation of the quadriceps and knee flexion hourly to get the joint moving. Restoring the muscle control of the knee and gaining joint range of movement is the initial goal of the first few day of therapy.
Next the physiotherapist assesses the patient for suitability for their first mobilisation, checking the operation note, the patient's medical observations and the condition of the legs themselves. The operated knee has to have enough stability to safely weight bear, as an epidural can cause profound loss of muscle power and prevent safe mobilisation until the drugs wear off. The patient is mobilised into standing by the physio with an assistant and encouraged to walk a small distance with elbow crutches or a Zimmer frame for more elderly persons. Operative protocol usually encourages normal weight bearing through the new knee as this helps restore normal patterns of muscular activity and improves circulation.
After discharge the physiotherapist will work on increasing joint range of motion, improving functional skills and improving muscular power and control of the knee. Typical exercises include knee flexion exercises to increase movement, inner range quadriceps for quads strength into extension and knee hangs to increase extension. Resisted work to the hamstrings uses reciprocal inhibition, the technique whereby working one muscle relaxes the antagonists, in this case increasing knee bend. Physios can do this manually or use resistance bands and encourage soft tissue massage to the scar to mobilise the tissue.
After individual work patients move on to gym based work, often in groups, to continue with strengthening muscles using gym balls or resisted rubber bands and dynamic activities such as standing up/sitting down and step-ups. Static bicycling and resisted exercises can be used to increase flexion further and training in joint position sense or proprioception is added. Proprioception is the ability of the joint to sense where it is in space, how fast it is moving and with what force, and is trained by balancing on a wobble board. Gait patterns are corrected and the physio teaches a normal pattern.
About the Author:
Jonathan Blood Smyth is Superintendent of a large team ofPhysiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiothrapists in Wimbledon or elsewhere in the UK.
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