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Postoperative Rehabilitation After Total Knee Replacement
Rehabilitative care is important to a patient’s functional outcome and satisfaction after both primary and revision total knee replacement. The functional improvement for patients after knee arthroplasty is well documented in the literature. Heck et al.1 showed excellent patient satisfaction in a prospective study of 291 patients. Similarly, positive impacts on patient function and health status have been reported using multiple outcome measures.2 Significant improvements in function have been demonstrated in both older and younger patients (>80 and <80). Despite the strong support for positive outcomes in total knee surgery, some patients’ total knees continue to have significant limitations.3,4 Walsh et al.5 compared 29 patients after total knee replacement with age- and gendermatched controls who had no known knee disease. Walking speeds, stair-climbing ability, and knee strength of the total knee group were significantly less than the control group at 1 year after surgery. In light of this, postoperative rehabilitation is critical to try to maximize the patient’s functional outcome after knee replacement.6,7 The majority of patients who have a total knee arthroplasty (TKA) identify pain and limited mobility as the primary reason for undergoing the procedure.8
PRINCIPLES AND STAGES OF REHABILITATION
Rehabilitation is an essential component for the overall episode of care surrounding patients undergoing total knee replacement.9 It should be goal oriented and guide the patient toward an optimal functional outcome.7 Incorporating the patient’s goals in the rehabilitation process is important to maximize compliance and gain an understanding of the needs of each individual patient.
Preoperative care for the total knee patient should focus primarily on education and strengthening.10 Patient expectations and being well informed of the postoperative course will not only improve the patients’ ultimate outcome, but will also improve their satisfaction with the procedure. Prior to surgery, a rehabilitative program of quadriceps strengthening, gait training with ambulatory aids, and anticipated needs at discharge should be done. Both the patient and the patient’s family or caregivers should participate in the preoperative care. Simple changes such as reducing household hazards and adapting furniture and sleeping arrangements can make the transition to home much easier.
Postoperative functional milestones are important. Functional milestones for the total knee patient include (a) independence and a postoperative exercise program to enhance muscle control and optimize knee range of motion; (b) the ability to transfer from a supine to sitting position and getting in and out of a bed; (c) the ability to ambulate a functional distance initially and ultimately without ambulatory aids; (d) the ability to navigate stairs; (e) the ability to safely and independently perform bathing and dressing activities; and (f) returning to as active a lifestyle as the patient wishes. Zabadak looked at four functional tasks that are critical to function at home after knee arthroplasty: sit-to-stand transfers, supine-to-sit transfers, ambulation of 100 feet, and stair climbing.11 Supine to sitting was found to be the easiest accomplishment followed by sit to standing and walking 100 feet. Stair climbing was the most difficult task to achieve after a total knee replacement. These goals should be discussed with the patient prior to surgery, and it should facilitate the postoperative rehabilitation.
DURING THE HOSPITALIZATION
For most patients, after knee arthroplasty, physical therapy is initiated on the day of or the day after surgery. The first focus should be on mobilization with getting up from a lying position in bed to a seated position, then next up and out of bed, then ambulation in concordance with knee range of motion. The majority of patients at our institution stay in the acute hospital setting for 48 hours after the arthroplasty, so most of these goals have to be obtained within the first 24 to 36 hours after the surgery.
The use of continuous passive motion (CPM) immediately after TKA has been abandoned at our hospital for two reasons: (a) its efficacy has not been clearly established in the literature and (b) the patients are in the hospital for such a brief period of time that the use of the CPM is probably not warranted.12–14 Multiple level one studies have looked at the effect of CPM, and no clear consensus has been found in the literature supporting or refuting its use and its influence on range of motion, length of stay, cost, need for manipulation, and narcotic use.15–20