Discharge Instructions & Physical Therapy Protocol for Total Knee Arthroplast

Recovery after knee surgery entails controlling swelling and discomfort, healing, return of range-of-motion of the knee joint, regaining strength in the muscles around the knee joint, and a gradual return to activities.  The following instructions are intended as a guide to help you achieve these individual goals and recover as quickly as possible after your knee surgery.

Comfort

• Elevation - Elevate your knee and ankle above the level of your heart.  The best position is lying down with two pillows lengthwise under your entire leg.  This should be done for the first several days after surgery
• Swelling - A cooling device may be provided to control swelling and discomfort by slowing the circulation in your knee.  Initially, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 10-minute intervals. If a cooling device is not provided at the time of surgery, place crushed ice in a plastic bag over your knee for no more than 20 minutes, three (3) times a day. Compression stockings worn on both legs will also reduce swelling and decrease the risk of blood clots. These should be used for 6 weeks following your surgery
• Pain Medication - Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication
• Antibiotic Medication - If an antibiotic has been prescribed, start taking the day of discharge from the hospital. Continue taking until the prescription is finished
• Blood Thinning Medication - You may be prescribed a blood thinning medication to help prevent blood clots after surgery. Take this medication as directed by the Medical Doctor
• Driving - Driving is not permitted until seen by your doctor at your first postoperative visit. Generally driving an automatic vehicle is allowed 2 weeks after Left Total Knee Replacement and 6 weeks after Right Total Knee Replacement

Activities

• Range-of-Motion - Move your knee through range of motion as tolerated. This must be done while sitting or lying down
• Exercises - These help prevent complications such as blood clotting in your legs.  Point and flex your foot and wiggle your toes. Thigh muscle tightening exercises should begin the day of surgery and should be done for 10 to 15 minutes, 3 times a day, for the first few weeks after surgery
• CPM - (Continuous Passive Motion Machine) - A Continuous Passive Motion (CPM) machine should be started the day after your surgery. This machine will be set at 30°. Motion on the machine should be increased at 10-15° per day or as much as tolerated, to a maximum of 110° in one week. The machine should be used 6 hours per day (i.e. 2 hours in the morning, 2 hours in the afternoon and 2 hours in the evening). Use of the machine will continue for 1-2 weeks, or until maximum flexion of the machine is reached (110°). DO NOT WEAR COOLING DEVICE WHILE USING CPM MACHINE
• Weightbearing Status- You are allowed to put all of your weight on your operative leg. Do this within the limits of pain. Two crutches or a walker should be used until directed to discontinue by Dr. Forsythe
• Physical Therapy - PT begins in the hospital the day after your surgery and continues once you are home. You should call the physical therapist of your choice for an appointment. A prescription for physical therapy, along with physical therapy instructions (included in this packet) must be taken to the therapist at your first visit. Depending on your ability to ambulate, you may have a home therapist arranged for you by the hospital prior to discharge. You should begin outpatient Physical Therapy as soon as possible
• Athletic Activities - Athletic activities, such as swimming, bicycling, jogging, running and stop-and-go sports, should be avoided until allowed by your doctor
• Return to Work - Return to work as soon as possible.  Your ability to work depends on a number of factors - your level of discomfort and how much demand your job puts on your knees.  If you have any questions, please call your doctor
• Antibiotic Prophylaxis - Having a Total Joint Replacement requires you to take antibiotics prior to all future procedures that may cause bleeding. These include
  • Dental cleaning
  • Dental procedures
  • Surgical procedures
  • Colonoscopies or Endoscopies
  • Notify your physician or dentist prior to any procedure so antibiotic treatment can be started

Wound Care

• Once home from the hospital, change your dressing daily by applying sterile 4x4’s with tape and reapply the compression stockings. The steri-strips and sutures will be removed at your first postoperative visit
• Tub bathing, swimming, and soaking of the knee should be avoided until allowed by your doctor - Usually 2 - 3 weeks after your surgery
• You may shower 5 days after surgery, after the initial dressing has been removed.  Cover the wound with plastic wrap while showering. Extreme caution and care should be taken when showering. Use of a shower chair is strongly recommended

Call your physician if

• Pain in your knee persists or worsens in the first few days after surgery
• Excessive redness or drainage of cloudy or bloody material from the wounds (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor
• You have a temperature elevation greater than 101°
• You have pain, swelling or redness in your calf
• You have numbness or weakness in your leg or foot
• You experience excessive bleeding while taking anti-coagulant medication

Return to the office

• Your first return to our office should be 2 weeks after your surgery.  Call Dr. Forsythe’s office to make an appointment for this first post-operative visit

Rehabilitation Program Following Total Knee Arthroplasty Guide for the Physical Therapist

Introduction

Total knee arthroplasty is a successful surgical procedure used to improve function and relieve the pain associated with knee osteoarthritis.  In order to restore normal function of the knee following the procedure, the rehabilitation program must focus on controlling pain/inflammation, returning normal knee range-of-motion, improving muscle strength, and re-establishing normal gait.

Typically, total knee replacements are successful, but if the patient participates in activities that are too strenuous for the replaced knee, failure can occur.  The patient should not pivot on the operative knee and should avoid torque or twisting forces.  Those activities that are permitted and restricted can be found at the end of the rehabilitation program.

The following rehabilitation program is offered to provide consistent, efficient, and goal directed rehabilitation following a total knee arthroplasty.  The rehabilitation program is divided into three phases.  Each phase has

• GOALS which should be accomplished prior to progressing to the next phase
• TIME FRAME provided for the purpose of guidance and protection but it is understood that patients will vary in their speed of recovery and progression should be focused on accomplishment of the goals
• TREATMENT RECOMMENDATIONS are the therapeutic modalities that can be used to safely achieve the goals for each phase

If any questions arise during the course of the total knee replacement rehabilitation program, do not hesitate to contact the surgeon.

PHASE I: MOBILIZATION

• TIME FRAME: Day 1 of outpatient physical therapy to 4 weeks
• GOALS
  • Minimize knee pain and inflammation
  • Less than 10° knee flexion contracture
  • At least 90° of knee flexion
  • Independent straight leg raise without a lag
  • Normal gait WBAT with assistive device if necessary
  • Normal patellofemoral mobility
• TREATMENT RECOMMENDATION: (ROM exercises and manual therapy continued until full ROM achieved)
  • Heel slides/wall slides (active, active assisted)
  • Patellar mobilizations
  • Tibiofemoral joint mobilizations
  • Gait training
  • Stair training
  • Quad set (NMES as necessary)
  • Ankle pumps
  • Glut sets
  • Hamstring sets
  • Knee extension hang/prone lying
  • Gastroc/Soleus stretch
  • Hamstring stretch
  • Quadricep stretch
  • SAQ/LAQ (NMES as necessary, PRE’s as tolerated)
  • Straight leg raise x4 (PRE’s as tolerated)
  • Standing hip flexion, extension, abduction, adduction (PRE's as tolerated)
  • Prone knee bend (PRE’s as tolerated)
  • Calf raises
  • Bridging
  • Ice
• PRECAUTION: Knee flexion greater than 90° and a knee flexion contracture of less than 10° should be accomplished by 6 weeks.  If a patient seems unable to achieve this, the physician should be contacted to determine the course of action necessary

PHASE II: STRENGTHENING

• TIME FRAME: 4-8 weeks
• GOALS
  • Full flexion and extension
  • Minimal knee pain and inflammation
  • Good quad control
• TREATMENT RECOMMENDATION
  • Stationary bike-minimal resistance
  • Standing knee flexion
  • Wall slides
  • Step-ups (forward, lateral)
  • Terminal knee extension
  • Backwards walking for terminal extension

PHASE III: FUNCTION

• TIME FRAME: 8-12 Weeks
• GOALS
  • Normal gait without assistive device (if patient did not use assistive device before surgery)
  • Full quad strength
• TREATMENT RECOMMENDATION
  • Cone walking
  • Single leg stance-eyes open, eyes closed, uneven surfaces
  • Perturbation training

ACTIVITIES RECOMMENDED ONCE ALL GOALS ACCOMPLISHED

• Low impact activities for cardiovascular exercise: Walking, bike riding, swimming, stationary skiing (Nordic-Track)
• Low impact sports: Archery, billiards, pool, bowling, cross-country skiing, fishing, golfing, horseback riding, hunting, low-impact aerobics, ballroom/square dancing, rowing, sailing, and scuba diving

ACTIVITIES NOT RECOMMENDED AFTER TOTAL KNEE REPLACEMENT
Running, jumping, baseball, basketball, football, softball, handball, climbing, down-hill skiing, martial arts, lacrosse, tennis, parachuting, racquetball, soccer, and volleyball
The patient should discuss with the surgeon participation in any activity in order to ensure it is safe for the replaced knee.