Masaryk University Faculty of Medicine REHABILITATION IN

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Masaryk University

Faculty of Medicine

REHABILITATION IN PATIENTS AFTER TOTAL KNEE ARTHROPLASTY

Bachelor´s Thesis

Physiotherapy

Bachelor’s Thesis Supervisor: Author:

Mgr. Veronika Mrkvicová Josh Tilrem

Brno, 2018 Name and Surname of the Author: Josh Tilrem

Title of Bachelor’s thesis: Rehabilitation in patients after total knee arthroplasty

Název bakalářské práce: Rehabilitace u pacientů po totální endoprotéze kolenního kloubu

Department: Department of Rehabilitation and Physiotherapy MF MU

Supervisor: Mgr. Veronika Mrkvicová Year of the Bachelor’s thesis defence: 2018

Summary: This Bachelor’s thesis is composed of two parts. The first part deals with the subject of total knee arthroplasty. The aim of this part is to describe the indication, surgical procedure and treatment, both in acute and long-term phase. The first part also contains the approach and management of the physical therapist and how to utilize proper rehabilitation. The second part is a case study and the aim is to describe the practical procedure of a specific rehabilitation after total knee arthroplasty. This include examination at admittance, discharge and rehabilitation provided by the author.

Souhrn: Tato bakalářská práce je složená ze dvou částí. Prní část pojednává o tématu totální endoprotézy kolenního kloubu. Cílem této části je popsat indikace, chirurgický přístup a léčbu, jak v akutní, tak chronické fázi. První část také zahrnuje fyzioterapetické postupy a provádění léčebné rehabilitace. Druhá část obsahuje kazuistiku a jejím cílem je přiblížit praktické postupy speciální rehabilitace po totální endoprotéze kolenního kloubu. To zahrnuje vstupní a výstupní vyšetření a rehabilitaci prováděnou autorem.

Keywords: Total knee arthroplasty, rehabilitation, physiotherapy

Klíčová slova: Totální endoprotéza kolenního kloubu, rehabilitace, fyzioterapie

I agree that this bachelor thesis will be archived in the Masaryk University of Brno library and will be quoted according to citations norms.

I declare that this bachelor thesis was written independently, under the supervision of Mgr. Veronika Mrkvicová, and that I stated all the literary and technical resources in the bibliography list.

30th of March, Brno Josh Tilrem

______

Acknowledgements: I would like to thank Mgr. Veronika Mrkvicová for her supervision, great leadership, professionality, advice and patience. I also would like to thank MUDr. Jarmila Siegelová for her guidance and Mr. D.V. for his excellent cooperation.

Contents

1 REVIEW OF THEORETICAL KNOWLEDGE ...... 8

1.1 GENERAL PART OF THE THESIS ...... 8 1.1.1 Definition of total knee arthroplasty ...... 8 1.1.2. Functional anatomy of the lower limb ...... 8 1.1.2.1 Bones ...... 8 1.1.2.2 Ligaments ...... 9 1.1.2.3 Joints ...... 12 1.1.2.4 Muscles ...... 14 1.1.3 Indications for TKA ...... 16 1.1.3.1 Injury ...... 16 1.1.3.2 Osteoarthritis ...... 17 1.1.3.3 Rheumatoid arthritis ...... 20 1.1.4 The surgical procedure of TKA ...... 22 1.1.4.1 Background ...... 22 1.1.4.2 Preparation ...... 23 1.1.4.3 Technique ...... 24 1.1.4.4 Postoperative care ...... 25 1.1.4.5 Contraindications ...... 25 1.1.4.6 Technical considerations ...... 26 1.1.4.7 Procedural planning ...... 27 1.1.4.8 Risks and complications ...... 28 1.2 SPECIALIZED PART OF THE THESIS ...... 30 1.2.1 Rehabilitation in acute phase after TKA ...... 30 1.2.1.1 Positioning ...... 30 1.2.1.2 Respiratory physiotherapy ...... 30 1.2.2 Therapeutic exercise after TKA ...... 31 1.2.3 Physical therapy modalities after TKA ...... 31 1.2.4 Occupational therapy after TKA ...... 33 1.2.5 Manual techniques after TKA ...... 33 1.2.5.1 Scar tissue mobilisation ...... 33 1.2.5.2 Patellar mobilisation ...... 34 1.2.6 Psychological and social aspects after TKA ...... 34

2 CASUISTIC ...... 36

2.1 BASIC DATA ...... 36 2.1.1 Case history ...... 37

2.2 EXAMINATION ...... 39 2.2.1 Kinesiological examination of the patient ...... 39 2.2.2 Manual muscle test ...... 43 2.2.3 Muscle shortening test ...... 44

2.3 SHORT-TERM REHABILITATION PROGRAM ...... 45 2.3.1 Realization of rehabilitation ...... 46 2.4 KINESIOLOGICAL EXAMINATION OF THE PATIENT AT THE COMPLETION OF COMPREHENSIVE REHABILITATION ...... 49

2.5 LONG-TERM REHABILITATION PROGRAM ...... 54

2.6 CONCLUSION ...... 55

3 REFERENCES...... 56

List of Acronyms:

TKA total knee arthroplasty ROM range of motion PROM passive range of motion ACL anterior cruciate ligament PCL posterior cruciate ligament CCD caput-collum-diaphyseal AROM active range of motion ECG electrocardiography PT physiotherapist

1 REVIEW OF THEORETICAL KNOWLEDGE

1.1 GENERAL PART OF THE THESIS

1.1.1 Definition of total knee arthroplasty

Total knee arthroplasty is a surgical procedure of the knee joint where damaged

parts are replaced by artificial parts [WILLIAM C.S, 2017].

1.1.2. Functional anatomy of the lower limb

1.1.2.1 Bones

The two hip bones os sacrum and ossa coxae are connected through articulatio sacroiliaca and symphysis pubica. This result in a stable ring structure which enable transferring of the bodyweight to the lower limb. Ossa coxae is composed of three parts, os ilium, os ischium and os pubis. All these three parts contributes to the formation of acetabulum in which the proximal part of the femur bone is connected by caput femoris which lies in the acetabulum. They make the CCD angle, and alterations of this angle may restrict movements. This will cause changes in the forces in the joint on the articular surfaces such as in coxa vara and coxa valga, this may further cause development of coxarthrosis or gonarthrosis. Other than this there is also the risk of fractures of the femoral neck which is a possibility due to the increased amount of bending stress in the situation of coxa vara [PAULSEN F, WASCHKE J, 2011].

In the distal part of the femoral bone there are so called condyles which are important for the movement in the knee joint.

The articular surfaces are retro positioned in relation to the axis of the femoral shaft. The femoral condyles curvature is also more posteriorly pronounced which results in a type of spiral curvature.

With the anatomical knowledge it is important to understand the degenerative diseases of the knee joint. The patella bone, commonly known as the kneecap articulates with the femur bone and serves to protect and cover the anterior articular surface of the knee joint. The proximal part of the tibial bone articulates with the femoral bone and this joint is the weightbearing part of the knee. The lateral and the bigger medial condyle are both flattened in the horizontal plane.

The fibula bone is located on the lateral side of the tibia. These two bones are connected both proximally and distally and is located below the level of the knee and therefor excluded as a part of the knee joint. However, it does make up the lateral part of the ankle joint (talocrural joint) which is formed by the bones of the leg- tibia, fibula and the talus bone of the foot.

The human foot is composed of a structure that is highly developed and biochemically complexed and serves to bear the weight of the human body. The bones in the foot can be divided into three groups: the 7 tarsal bones, the 5 metatarsal bones and the 14 phalanges [PAULSEN F, WASCHKE J, 2011].

1.1.2.2 Ligaments

Ligaments connect bones to other bones and are composed of fibrous connective tissue. Ligg. sacroiliaca ateriores stabilise each sacro-iliac joint ventrally while lig. iliolumbale stabilise the sacro-iliac joint superiorly [PAULSEN F, WASCHKE J, 2011].

Lig. pubicum superius and inferius bridge the pubic symphysis. Membrana obturatoria almost completely close the foramen obturatum and only leaves a small passage for the neurovascular bundles to the medial side of the thigh.

Lig. sacrospinale connects sacrum with spina ischiadica horizontally and dorsally with lig. sacrotuberale which runs obliquely to the tuber ischiadicum, Both ligaments, together with insisura ischiadica, forms foramen ischiadicum majus and minus. These openings are important for nerves and blood vessels of the plexus sacralis. Inferiorly to lig. inguinale there is a space which is divided by arcus iliopectineus into the lateral lacuna musculorum and the medial lacuna vasorum. Through these spaces in the direction of anterior side of the thigh runs neurovascular structures.

Lig. iliofemorale, lig. pubofemorale and lig. ischiofemorale in the hip joint surrounds the femoral head in a spiral form. Their importance is to prevent posterior tilt of pelvis and limit the ROM in hip. Lig. transversum acetabuli together with labrum acetabuli closes the acetabulum inferiorly and guides the femoral head.

In the knee joint there are external ligaments and internal ligaments which are positioned within the capsula fibrosa. Lig. patellae, is one of the external ligaments and is a continuation of the m. quadriceps femoris tendon and the retinacula patellae mediale and laterale. These ligaments have both superficial longitudinal and deep circular fibers and can both be viewed as parts of m. quadriceps femoris tendon. Ligg. collateralia tibiale and fibulare are located medially and laterally and inserts into the tibia and fibula. Lig. collaterale tibiale is important in the flexion of the knee joint because it serves to fix meniscus medialis into its position. When the knee is extended the collateral ligaments are stretched which do not make it possible for rotational movement. During knee joint flexion, the collateral ligaments are relaxed and enables rotational movement. The collateral ligaments are very important for the stability of the knee joint. Injuries of these ligaments cause instability and laxity of the joint [PAULSEN F, WASCHKE J, 2011]. 10

There is a fat pad positioned between capsula fibrosa and capsula synovialis and is connected to ACL. On the posterior side of the knee you can find ligg. popliteum obliquum and arcuatum. There are also several internal ligaments inside the joint capsule- ACL and PCL. ACL goes from the lateral femoral condyle to the anterior part of tibia called intercondylaris, while PCL goes from medialfemoral condyle to the posterior part of intercondylaris on tibia. Lig. meniscofemorale anterius and posterius serves as a connection between the meniscus lateralis and the medial condyle. The effect of this is to support PCL.

In the ankle the lateral lig. talofibulare posterius and parts of lig. collaterale mediale supports the posterior side. Medially the ankle joint is stabilized by lig. collaterale mediale (deltoideum), which consists of four parts and it is fan shaped. The four parts are: pars tibiotalaris posterior and anterior, pars tibiocalcanea and pars tibionavicularis, these parts connect to its respective bones. On the lateral side of the ankle joint there are three single ligaments and they give additional stabilisation to the talocalcaneonavicular joint which makes out the lower part of the ankle joint [PAULSEN F, WASCHKE J, 2011].

FIG 1. ANATOMY OF THE KNEE JOINT

Picture taken from Patel orthopaedic hospital.

(http://www.patelhospital.co.in/articles)

1.1.2.3 Joints

Sacro-iliac joint enables transmission of weight from the trunk to the pelvic girdle. The hip joint is a cotyloid joint which means that it has a special form of ball-and-socket joint. Acetabulum which covers more than half of the femoral head forms the socket together with labrum acetabuli. The angle made of the transverse plane and acetabular rim is 40 degrees. This joint is reinforced by strong ligaments in the hip and helps to divide weight onto lower limbs. In some orthopaedic studies there has been shown that the position and shape of the acetabulum together with the femoral head contributes to major factors in degenerative changes of the hip joint (coxarthrosis) [DRAKE RL et. al, 2014].

There are three axes of movement in the hip joint: extension-flexion, abduction-adduction and lateral rotation-medial rotation. The ROM is limited by strong ligaments and strict guidance of the acetabulum, which enables a stable upright position of the body due to restricted extension. Flexion is possible in much higher ROM due to exclusively restriction of soft tissues and is very important for walking [NEUMANN A.D, 2016].

The knee joint is a bicondylar joint which functions as a pivot-hinge joint. It has two axes of movements which extends through both femoral condyles, extension-flexion in the transverse axis and rotational movements in the longitudinal axis. In the knee, femur articulates with tibia and patella, and they come together in the same joint capsule where the tibial condyles form the socket of the joint and the femoral condyles makes out the head and the upper articular surface of the tibia. The articular surfaces are enclosed by the joint capsule.

There are several bursae in the knee and some of them communicate with the joint capsule, for example bursa suprapatellaris. If there is a high repetitive mechanical stress, inflammation may develope (bursitis). In chronic inflammation like in the case of rheumatic diseases, fusion and enlargement of bursae can occur [DRAKE RL et. al, 2014].

Baker’s cyst is a condition where there is a fusion of bursa musculi semimembranosi with bursa subtendinea musculi gastrocnemii medialis.

The knee joint is strained by the weight of the body which can cause degenerative changes (gonarthrosis). Injuries to ligaments and the menisci are also common because the knee lacks strong muscular guidance, due to this patellar luxation can occur. In knee joint flexion there is a combination of rolling and sliding movement, and there is up to 20 degrees posterior movement of the condyles. The shape of the condyles of femur and tibia are not precisely the same. The lateral femoral condyle moves while the medial condyle stay in the same position and rotate together with femur to some extent outwards. In the end part of extension, the knee has a 5-10 degrees lateral rotation where the medial condyle loses its contact with the medial meniscus.

Injuries involving the meniscus are common, and most typically is the medial because it is fixated to the bone and capsule. Sudden rotational movements in combination with weighted flexed knee are typical acute injuries, these cause pain and inhibit the passive and active extension. Malposition relates to chronic degenerative changes, and the collateral ligaments prevent abduction-adduction movement of the knee joint. There is a bigger extent of lateral rotation than medial due to the crucial ligaments. The tension of the collateral ligaments makes rotation movement of the knee only possible during flexion.

Tibia, fibula and talus form the ankle joint which is a synovial and functional hinge type joint. Syndesmosis of tibiofibularis connects the tibia and fibula together, and they form the socket of the ankle joint through the malleolar fork. Talus bone of the foot is the ball of the joint.

The movements of the foot are mainly elicited by upper ankle joint and talocalcaneonavicular joint in the lower part. Movements performed by the ankle joint is dorsiflexion and plantarflexion. Movements like inversion and eversion is performed by joints in the foot, such as the subtalar joint [DRAKE RL et. al, 2014].

When it comes to injuries, the ankle joint is more prone than the talocalcaneonavicular joint due to the support of ligaments in the malleolar region is not very strong. Tear of the lateral ligaments is most commonly seen in hyper supination trauma [DRAKE RL et. al, 2014].

1.1.2.4 Muscles

The muscles of the hip and thigh have several important functions such as normal gait, erect the body from supine position as well as to maintain an upright position. M. iliopsoas is the most important hip flexor located on the anterior side. In conditions like spasticity or dystonia where the hip is in lasting flexed position due to the contraction of m. iliopsoas, it is not possible to stand in upright position.

On the lateral aspect we find m. tensor fasciae latae. It inserts on the iliotibial tract and function as a tension band which reduce the bending stress and therefor protects the thigh bone from fractures. This muscle flexes the hip joint and is counted as a dorsolateral muscle due to its innervation. M. sartorius is a long superficial muscle which runs down on the anterior aspect of the thigh, and its main functions are hip and knee flexion.

M. quadriceps femoris is located on the ventral side of the thigh and consist of four heads- m. vastus lateralis, medialis and intermedius and m. rectus femoris. Their common tendon is the patella tendon and their fibers continues from lig. patellae to the tuberositas tibiae and helps to make extension of knee joint. M. rectus femoris contributes to flexion of the hip and this muscle is crucial for the body to get in an upright position from squatting. On the medial side of the thigh is located the group of Mm. adductores. They make out several layers where the most superficial ones are m. gracilis, m. adductor longus and m. pectineus. Deeper you can find m. adductor magnus and m. adductor brevis. The adductor group of muscles are vital for the stabilisation of the hip during standing and walking [PAULSEN F, WASCHKE J, 2011]. 14

The dorsolateral group includes M. gluteus maximus, medius and minimus. M. gluteus maximus is a strong extensor of the hip and lateral rotator which is used when climbing stairs. M. gluteus medius and m. gluteus minimus are two very important abductors and medial rotators. They are both used during walking and standing and acts to stabilise the hip to prevent tilting of the pelvis. The Trendelenburg’s sign we can see when standing on one leg and the pelvis tilts to the contralateral side. The lateral rotators include m. piriformis, Mm. obturatorii internus and externus, Mm. gemelii superior and inferior and m. quadratus femoris.

Located on the dorsal aspect of the thigh we can find ischiocrural muscles also known as hamstrings muscles which consist of m. semimembranosus, m. semitendinosus and m. biceps femoris. These muscles pass over two joints which makes them facilitate extension of the hip joint. They are also the strongest flexors of the knee joint. The common insertion on the medial tibial condyle of Mm. sartorius, gracilis and semitendinosus is typically referred to as “Pes anserinus superficialis” while the more deep lying insertion of the m. semimembranosus is named “Pes anserinus profundus”.

On the leg there are ventral, lateral and dorsal muscles. Their position in relation to the movement of the axes in ankle and foot joint is fundamental to understand their function. Located ventrally is m. tibialis anterior which serves for dorsiflexion, m. extensor digitorum longus and m. extensor hallucis longus which serves for dorsiflexion and extension of the toes. They are coursed anertially to the transverse axis of the ankle joint. Mm. fibularis longus and brevis are located on the lateral side of the leg. They serve as plantarflexors and are also the most important pronators. The tendons of these muscles are located dorsally to the flexion-extension axis.

In the dorsal superficial view lies m. triceps surae. It is a muscle with three heads- m. gastrocnemius medius and lateralis and m. soleus which serve for plantarflexion and supination of the foot [PAULSEN F, WASCHKE J, 2011].

M. gastrocnemius also passes the knee and help with flexion in this joint. The three heads together insert at the calcaneus bone via the Achilles tendon.

Located deeply in the dorsal aspect is m. tibialis posterior and serves for plantarflexion and supination of the foot. M. flexor digitorum longus and m. flexor hallucis longus serves for flexion of the toes. M. popliteus is a specific knee joint stabiliser muscle which prevent extensive lateral rotation. Under m. popliteus lies the bursa subpoplitea which communicates with the knee joint cavity. M. plantaris is a rather insignificant muscle, its function is flexion of the knee joint [PAULSEN F, WASCHKE J, 2011].

1.1.3 Indications for TKA

1.1.3.1 Injury

The knee joint is a big joint and therefor a common site of injury. The injuries can be divided with those of acute onset and those which are developed over time due to overuse. Knee injuries may further in some cases be a cause for the surgical procedure of TKA.

Acute injuries happen during abnormal twisting, bending, direct blows or falling. Symptoms are pain and swelling, and bruising may show within a few minutes after the injury. There can also be nerve and vessel damages which can cause the leg to change in colour (pale and blue) together with feeling of numbness, cold, pricking and weakness. In the group of acute injuries to the knee we can include- fractures, sprains, strains and tears of ligaments, tendons, menisci and dislocations [Orthoinfo.aaos.org. MARCH 2014].

Some of the most common ones are fractures, typically of the patellar bone, due to high forces afflicted to the knee, but we can also see fractures of the lower aspect of the femoral bone and upper aspect of tibial and fibular bone. Sprains, strains and tears of ACL, PCL and collateral ligaments may also occur, which is often caused due to abnormal twisting and bending often in correlation with forces from different directions. Meniscal tear may occur during sports but also due to arthritis or aging. Other injuries may be dislocations of the patellar, tibial and femoral bones. There can be partial or complete dislocation typically caused by high force such in motor vehicle accidents, during sports or in falls but also if there is an abnormal structure in the knee.

Overuse injuries is developed over time and with repetitive or extended pressure, typically caused by sports activities or occupation. This continued irritation over time can lead to inflammation in tissues surrounding the knee for example bursitis, tendinitis, iliotibial band syndrome, plica syndrome (thickening or folding of knee ligaments) and patellofemoral pain syndrome (pain in anterior aspect of the knee [Orthoinfo.aaos.org. MARCH 2014].

1.1.3.2 Osteoarthritis

Osteoarthritis is a non-inflammatory process with the possibility to affect all the synovial joints. Characteristically osteoarthritis affects the larger synovial joints like hip, knee, shoulder, elbow, facet joints of the spine and first metatarsophalangeal joint of the foot. Osteoarthritis in carpometacarpal joint at the base of the thumb and interphalangeal joints of the hand may also occur. The most common site is the knee and is the most common form of the primary osteoarthritis due to the “wear-and-tear” which is a physiological cause. Cause for secondary osteoarthritis is trauma, particularly if the surface of the joint is damaged for example due to fracture, infection or congenital conditions [BONNIN M, CHAMBAT P, 2008].

Osteoarthritis starts with microscopic damage which may be seen in the surface layers of articular cartilage. In attempts to repair microscopic damage, the disease is self-perpetuating which increases protelytic enzyme activation and levels of interleukins, particularly IL-1, that causes a further degradation of the cartilage. This will eventually lead to more softening of the cartilage (chondromalacia) as the disease proceeds and make it fissured and frayed. Mechanical failure in form of microfractures will be the outcome due to softening of the cartilage which causes abnormal transmission of load to the subchondral bone. By producing abnormal bone called osteophytes the bone tries to heal itself, later the joint space narrows when the subchondral bone gets exposed.

In X-ray pictures of osteoarthritis, we can find osteophytes, thinning of cartilage, hardening of bone in response to load (subchondral sclerosis), and subchondral cysts which is a result from microfractures. Clinical signs and symptoms include instability due to the loss of the normal joint mechanics, loss of movement and pain which affects the sleep and increase with movement and finally crepitus.

To diagnose osteoarthritis imaging methods such as X-ray, MRI and CT are used. X-ray is used to find what is written above, MRI to detect early cases due to the great visualisation of cartilage and CT to see gross joint destruction- the cartilage is not visible, but we can elicit bone damage. Arthroscopy may be used to stage the severity of osteoarthritis and to treat cartilage damage in limited areas, although it is not used as the primary diagnostic tool.

Patient history (anamnesis) and examination is a vital part of the diagnosis. To stage the severity of the osteoarthritis there is a grading system (0-4) used when viewed through an arthroscope. 0-normal, 1-chondromalacia, 2-partial-thickness defect with surface fissures, 3-fissures extending down to subchondral bone, 4-exposed subchondral bone. The severity of symptoms varies. Someone with mild osteoarthritis may perceive more pain than one with severe osteoarthritis [BONNIN M, CHAMBAT P, 2008].

It is a combination of expectation and functional demands when it comes to the perception of severity of the symptoms

First conservative treatments should be tried. This may include weight loss to reduce joint load, modification of activities to avoid high-impact sports, using a stick when walking etc., physiotherapy to maintain ROM and muscle strength and help to reduce instability, also non-steroidal anti-inflammatory drugs and glucosamine may be effective in some cases. If these options fail, surgical treatment is indicated. It may be injections such as steroids, local anaesthetics and hyaluronic acid, arthroscopic intervention, osteotomy for reducing pain by realignment or arthrodesis (fusion of the joint). However, arthroplasty is the most common way of surgical treatment and today most of the joints can be replaced [BONNIN M, CHAMBAT P, 2008].

FIG 2. OSTEOARTHRITIS OF THE KNEE

Picture taken from American academy of orthopaedic surgeons.

(https://orthoinfo.aaos.org/en/treatment/osteotomy-of-the-knee/)

1.1.3.3 Rheumatoid arthritis

Rheumatoid arthritis is the most common form of inflammatory arthritis and affects more women than men. Rheumatoid arthritis has a strong genetic component and is a multisystem autoimmune disease. The aetiology is not clear, however there are theories involving environmental toxins or an infectious component in a combination with the genetic predisposition. The pathophysiology of rheumatoid arthritis is T-cell-driven autoimmune response and therefore antibodies are present inside tissues. In comparison to osteoarthritis, rheumatoid arthritis has multisystem manifestations which affect several parts: Synovial joints and its associated tendons and ligaments (typically symmetrically distributed), skin (rheumatoid nodules), eyes (dry), cardiovascular and bronchopulmonary system (increased risk of atherosclerosis, pericarditis and rheumatoid nodules in the lungs), kidneys (renal impairment), blood (lymphoma, autoimmune anaemia), nervous system (peripheral neuropathy, compressed nerves), spleen and immune system (Felty’s syndrome which is the combination of rheumatoid arthritis, splenomegaly and neutropenia).

For the diagnosis of rheumatoid arthritis, some criteria has been developed which involve common points such as- two or more swollen joints, morning stiffness lasting for at least six weeks and more than one-hour, positive rheumatoid factor or antibodies. The differential diagnosis includes: psoriatic arthropathy, systemic lupus erythematosus, ankylosing spondylitis, osteoarthritis, crystal arthropathies and reactive arthritis or Reiter’s syndrome. Typically, the X-ray findings include- joint subluxation and malalignment (cause of the typical deformities seen in hands and feet), soft tissue swelling, periarticular osteopenia (loss of bone density) and periarticular erosions (causing the formation of cysts). As a part of the diagnosis, X-rays of hands and feet are performed together with other affected joints as well. Rheumatoid arthritis is a rather complex disease which requires cooperation of rheumatologists and orthopaedic surgeons and others from the medical team [WILLMOTT H, 2016].

Pharmacotherapy is a part of the treatment and includes anti-inflammatory drugs, disease modifying anti-rheumatic drugs among others. The surgeon`s role will be focused on- instability of joints caused by destruction of ligaments, which may be corrected by joint replacement, pain caused by instability and synovitis, nerve compression and tendon dysfunction caused by inflamed synovium [DRAGOSLOVEANU C et al, 2017].

FIG 3. RHEUMATOID ARTHRITIS OF THE KNEE

Picture taken from Kori kryotherapy.

(https://www.korikryotherapy.com/living-ra-pain-cryo-can-help/)

1.1.4 The surgical procedure of TKA

FIG 4. TOTAL KNEE ARTHROPLASTY PROCEDURE Picture taken from Orthoteam, orthopaedic medical center. (https://www.orthoteam.gr/blog/personalized-total-knee-replacement/)

1.1.4.1 Background

TKA has been practised for over fifty years, and in the beginning, this was not very successful, until about thirty years ago when the understanding of TKA really developed. Over time there has been big improvements and the knowledge about knee function and mechanics has expanded. Modifications in materials, how they are used and processed, makes them much more durable.

In the 1940s, the first artificial implants were made with molds that they tried to fit into the femoral condyles, but problems arose regarding long lasting pain and loosening [PALMER S.H, 2016].

It was not until the beginning of the 1970s things really started to develop in the right direction. Frank Gunston started to get a deeper understanding about the knee and its mechanics, how the femoral condyles roll and slide on the tibia with multiple instant center of rotation. He had some early success with his polycentric knee replacement, however in the end it did not work because of insufficient fixation of the prosthetics to the bone.

A few years later, hospital for special surgery developed the “total condylar prosthesis”, which focused on mechanics rather than an attempt to mimic the normal knee movement. It was the most successful one up to that point. Some years later, this was improved a lot and they managed to involve normal kinematics into the artificial device, with the goal to improve ROM. The hospital for special surgery also tried a prosthesis with more natural kinematics, with strong belief that the retained cruciate ligaments would provide knee motion. Even up until today, there are still ongoing discussions about whether or not the knee ligaments should be sacrificed [PALMER S.H, 2016].

1.1.4.2 Preparation

Regional or general anaesthesia are both possible options when performing TKA, and the preferred choice is connected to the state of the patient. It has been demonstrated that the usage of epidural anaesthesia may result in a lower risk of deep vein thrombosis. In the preoperative phase, the medical evaluation of the patient is fundamental, and this includes; different image methods to assess several views in different angles of the knee, laboratory tests such as complete blood count, erythrocyte sedimentation rate, serum electrolytes, urinalysis and urine culture, renal function, prothrombin time and activated partial thromboplastin time, to ensure that the patient can tolerate anaesthesia and blood loss of up to 1500ml over the perioperative period [WILLIAM C.S, 2017].

Good cardiopulmonary health is crucial, and ECG is performed in older patients.

About thirty minutes in advance of the surgery, the patient is given antibiotics and antithrombotic medication. Compression stockings are used during the operation to prevent the manifestation and proceeding of venous problems such as thrombosis, phlebitis and oedema.

[WILLIAM C.S, 2017].

1.1.4.3 Technique

The surgery is performed either by the medial parapatellar approach on the ventral side of the knee or in some cases through lateral or subvastus method. The femoral bone is cut on the distal end to ensure proper positioning in relation to the mechanical axis for correct alignment. Then, the tibial bone is cut in the proximal end for the same purpose. Enough bone is removed for the new artificial parts to be placed in the correct level of the joint line, to achieve stability in the knee. The alignment is vital to distribute weight bearing and avoid eccentric loading of the replaced joint. Release of deformed ligaments surrounding the contracted knee is performed and patellofemoral tracking is balanced if needed. This is done through lateral release or medial reefing, in more severe cases it may need to be resurfaced.

Polymethyl methacrylate cement is used to put the parts of the prosthesis in place in the cemented type, while in the uncemented type the technique of press-fit and ingrowth in bone is used to fixate the parts.

The goal of TKA is to improve ROM, decrease and relief pain, and bring back the normal mechanical axis of the lower limb [PALMER S.H, 2016].

1.1.4.4 Postoperative care

After surgery, the patient is closely observed for 24 hours, receiving analgesia and monitoring hydration status. Drains are usually removed during this period. Verticalization should be done as soon as possible, usually the second postoperative day, and with walking aid. Cryotherapy is a good way to reduce the swelling and pain. Instructions about weight bearing should be followed according to surgeon, and PROM should start in the early stages after. It can be performed by using machines such as Moto med or PROM machine for lower limbs, or by other exercises provided by the PT supervising the patient during the hospital stay. The PT will help with strengthening of the knee muscles and improving ROM, even though it may be painful it is important to decrease the risk of complications. Length of the period of stay depends on the hospital, doctors preference, and state of the patient.

After discharge, the postoperative care will continue at home. Medications to prevent thromboembolic conditions are usually continued for some time. According to the American Association of hip and knee surgeons, the recovery from TKA may take up to 3 months, hence when the patient returns home, it is important that he or she follows the instructions from the doctors, PTs and nurses for optimal recovery [PALMER S.H, 2016].

1.1.4.5 Contraindications

Contraindications for TKA can be divided into absolute and relative. The absolute contraindications include severe vascular disease, knee sepsis, present infection, dysfunction of the extensor mechanism, well-functioning knee arthrodesis and recurvatum deformity secondary to weakness of muscles [SCOTT D.R, 2014].

In the category of relative contraindications belongs medical conditions of the patient that may jeopardize utilisation of safe anaesthesia, surgery and rehabilitation. Other possible relative contraindications are obesity, neuropathy of the joint, history of osteomyelitis of the joint and conditions of the skin at the site of surgery, like for example psoriasis [SCOTT D.R, 2014].

1.1.4.6 Technical considerations

When it comes to technical aspects of the TKA, anatomy plays an important role. The mechanical axis of the lower limbs run from the center of the hip, passing the middle of the knee and goes all the way down to the center of the ankle. If any deformities are developed and the mechanical axis is changed, surgery is performed to normalize the gait and avoid eccentric loading.

The different movements in the knee joint is a product of how ACL, PCL, medial and lateral collateral ligaments and the articulating surfaces of femur and tibia are shaped. The four ligaments make up a linkage system in the knee joint.

Flexion and extension of the knee is made by sliding and rolling movements. The lateral and medial condyles of the femur are asymmetric, causing the lateral condyle to roll 20% more in flexion of the knee than the medial condyle. This gives explanation of the locking mechanism in knee extension, since the greater rolling of the lateral femoral condyle causes coupled external rotation of tibia.

ACL resist varus or valgus rotation of tibia, particularly if the collateral ligaments are gone. But the primary function is to protect against tibial displacement on femur during flexion of the knee and to control this tibial mechanism in terminal extension [BONNIN M, 2012].

The function of the PCL is to control external rotation of tibia when knee is flexing, permit rollback of femur in flexion and resist change of tibia relative to femur posteriorly. In TKA it has been proved that PCL retention biomechanically gives a normal rollback of the femoral component on the tibial component.

The medial collateral ligament control external rotation and restrain valgus movement of the knee joint, while the lateral collateral ligament resists internal rotation and restrain varus movement.

The patellofemoral joint movement is done by gliding and sliding. Patella moves distally on the femoral bone when the knee is flexing. The patellofemoral joints attachments are to the quadriceps tendon, patellar ligament and femoral condyles anteriorly. Knee extension is the work of the muscles and ligaments surrounding the patellofemoral joint. The function of the Patella is to act as a kind of “pulley” for the force developed by quadriceps muscles, and to transmit that force to lig. patellae and femur. In this way, the quadriceps muscle in relation to center of rotation of the knee, increases its mechanical advantage [BONNIN M, 2012].

1.1.4.7 Procedural planning

There are several types of surgeries that could be used for people with degenerative knee disease. In mild cases with recurrent persistent effusions and mechanical symptoms, debridement by arthroscopy could be performed. Those with medial tibiofemoral compartment disease, varus deformity of the knee which is possible to correct and has stable collateral ligaments, should undergo valgus osteotomy of proximal tibial bone. In the opposite case, varus osteotomy of distal femoral bone should be done when there is lateral tibiofemoral compartment disease, correctable knee valgus deformity and stable collateral ligaments [PALMER S.H, 2016]. 27

These surgeries are mainly performed in young patients due to the concerns regarding the duration of TKA. They restore lower limb mechanical axis and reduce the load of the knee joint with diseased compartment, and is the procedure of choice in cases with advanced symptomatic degenerative changes in the knee joint, present in one or more compartments. More seldom performed is arthrodesis or fusion of the knee, however it is a possibility in people with chronic sepsis, extensor mechanism deficit or young people who has tricompartmental disease and need stability and durability. [PALMER S.H, 2016].

1.1.4.8 Risks and complications

There are many risks and complications from undergoing TKA, and these should be carefully considered along with the benefits before proceeding with the surgery.

Infection could develop either during the surgery, in the perioperative state as well as years later due to the presence of a foreign body. Symptoms like heat, swelling, pain and even signs of sepsis are indicative, and an aspiration may be taken in an aseptic theatre to identify the organism. If an infection would occur up until a few weeks post-surgery, there is still a possibility to save the joint. The patient must go back to the theatre where debridement, washout and change of plastic liner will be done. However, if the patient comes too late or this procedure fails, the joint must be revised and prolonged treatment with antibiotics will be needed [JUNAID K et al, 2017].

Nerve or blood vessels, typically those closely located to the knee, such as common peroneal nerve, tibial nerve and popliteal artery, could be damaged during the surgery by for example traction or a saw blade. After the anaesthetics start to reduce, pulse and sensation should be examined to exclude this [BELLEMANS J et al, 2005]. 28

Instability can be occur if the balancing during surgery was not properly achieved or if the collateral ligaments of the knee has been damaged.

Wear and loosening due to debris that is generated can eventually lead to osteolysis which will cause pain and instability of the knee.

Deep vein thrombosis and pulmonary embolism may arise when the body’s clotting process is stimulated while trying to close the surgery wound and stop it from bleeding. Clotting factors and blood cells create the clots, and that may block the blood flow, and they can occur in the ongoing surgery, within a few hours or even weeks after.

Lasting pain and stiffness after surgery due to for example scar tissue may inhibit ROM of the knee joint, whereas allergic reactions to artificial components could lead to rejection of the implant.

Complications from anaesthesia can cause vomiting, dizziness, drowsiness, shivering, sore throat, discomfort and irregular heartbeat.

Problems with healing of the wound and complications from blood transfusion due to transmitted infection or haemolytic reaction can occur [BELLEMANS J et al, 2005].

1.2 SPECIALIZED PART OF THE THESIS

1.2.1 Rehabilitation in the acute phase after TKA

1.2.1.1 Positioning

The mobility in the knee joint is decreased after TKA. Positioning should be performed to prevent shortening or contracture of muscles surrounding the knee and to improve ROM. The initial days after TKA, the patient spends a lot of time in bed lying in the same position for several hours, which may cause restricted ROM and development of contractures that may be painful for the patient. The positioning must be safe for the patient and the precisely targeted impact of external forces is essential. For improvement of flexion and extension of the knee, pillows can be used in supine and prone position [PORTER S, 2013].

1.2.1.2 Respiratory physiotherapy

Respiratory physiotherapy (RP) aids the mobilisation and remove secretions from the airways. It may also help to improve the efficacy of ventilation, maintain or increase exercise tolerance, reduce breathlessness and the work of breathing muscles [KENYON K et al, 2009]. Some treatments involve postural drainage and manual techniques to enable chest clearance. Devices like flutter, acapella and triflow can also be used to assist respiratory care, all of which can also be taught to the patient for self-management [DENEHY L, 2016].

1.2.2 Therapeutic exercise after TKA

Following TKA surgery, regular exercise where the focus is to improve and restore strength and mobility, is necessary to reach full recovery. The PT and the orthopaedic surgeon may recommend 20-30 minutes of exercise 2-3 times daily in addition to walking. In the early post-operative stage, it is important to improve blood circulation to legs and feet, and the exercise should start as soon as possible for a gradual return to everyday activities. Some exercises may include straight leg raises, ankle pumps, isometric contractions of M. quadriceps, assisted flexion of the knee joint, straightening of the bed positioning to prevent flexed contracture, and passive ROM machine or motomed. An uncomfortable feeling or pain may be felt initially, but the exercises will help speed up the recovery and decrease pain eventually. Verticalization should start as soon as possible, followed by gait and stair climbing, assisted with devices such as a walker or crutches. The weight bearing percentage is set according to the orthopaedic surgeon’s recommendation, and the level of exercises are gradually increased according to patient progression, moving from passive to active exercises, then active resisted, and from closed kinetic to open kinetic chain exercises. Equipment such as over ball, rubber bands, dumbbell’s, exercise balls and so on will give more variety to the exercise and make it more fun and interesting for the patient, in addition to improving the sensory motoric skills. Proprioceptive neuromuscular facilitation (PNF) can also be incorporated to improve ROM [Orthoinfo.aaos.org. JANUARY 2015].

1.2.3 Physical therapy modalities after TKA

Cryotherapy can be used as a part of the medical therapy or rehabilitation process to reduce swelling after surgery, or relieve muscle pain and sprains [PRENTICE E.W, 2011].

Physical modalities can be applied generally or locally with low temperature ice packs, sprays, nitrogen, whole body or partial chambers. Cryotherapy causes immediate vasoconstriction with reflexive vasodilatation, in addition to decreasing local metabolism, enzyme activity and demand of oxygen. These very low temperatures will also slow down the velocity of nerve conduction and decrease activity of muscle spindle fibres.

Electrostimulation is a type of electrotherapy used for stimulation of denervated muscles, where the goal is to prevent atrophy. Usually, there is a neurological problem with either peripheral or central paresis, and very often a monopolar stimulation is applied to motor points in the muscle, using a ball electrode (cathode).

Electrogymnastics, also called myostimulation, is a type of electrotherapy for weakened muscles. Electrical impulses cause involuntary muscular contraction, and the goal with this stimulation is to strengthen the muscle and integrate correct timing of the contraction. This type of electrotherapy can be used after surgery or long-time immobilisation, when the patient can’t provoke muscle contraction voluntarily, or for better sports performance. Applying it to muscles with active trigger points is contraindicated.

Transcutaneous electrical nerve stimulation (TENS) is a type of electrotherapy used for non-pharmacological pain relief and to decrease intense itching. An electrical current is produced in a device for stimulation of nerves. The electrodes can for instance be placed at the point of pain, on extremities right above the nerve which innervates the painful area, or on acupuncture points. Its mechanism of action is based on the theories of gate of pain, endorphins and coding reactions.

LASER (light amplification by stimulated emission of radiation) is a form of light therapy, where low-power lasers can be used. It is believed that it stimulates and encourages the cells to improve or start functioning again. In physiotherapy, visible radiation and infrared radiation is used. Direct effects include locally increased temperature in tissues and biochemical reactions on the macromolecular level [PRENTICE E.W, 2011].

Indirect effects are analgesic due to release of endorphins, reabsorption of swelling and normalization of pH, anti-inflammatory due to activation of monocytes and macrophages which increases phagocytosis, and bio stimulation due to supply of energy to cells with energetic deficit. Indications for its use is by examples given the reduction of scarring, functional and structural musculoskeletal disorders, stimulation of motor points, decubitus and post-traumatic state. Some contraindications are radiation of eyes and thyroid gland, epilepsy, fever, tumours, pregnancy and photo dermatosis [PRENTICE E.W, 2011].

1.2.4 Occupational therapy after TKA

Occupational therapy can be provided after TKA to help the development of individual skills, aid the activity of daily living and endorse self-sufficiency. The occupational therapist may instruct on sitting, standing, different types of transports (bed, tub, toilet etc.) and lower body dressing. Assisting equipment that could be used is walker, leg lifter, tub bench, shower chair, toilet elevation seat and adaptive equipment for dressing of the lower body [KOLAR P, 2014].

1.2.5 Manual techniques after TKA

1.2.5.1 Scar tissue mobilisation

After TKA the patient will have a scar running over the knee joint. It is important to close the surgical wound without infection and remove the stiches at an appropriate time to promote good healing with minimal scarring. The PT may perform scar mobilisation or massage to help with the remodelling process in addition to decreasing scar tissue adhesions and formations to restore normal functional mobility. This may be achieved by performing pressure massage of 33

the scar and surrounding tissues, using the ball of the thumb or finger to gently push inwards and do circular movements under constant pressure to the skin against the base. Other techniques can be soft tissue stretching of the skin and deeper layers, typically using the fingers to create an “S-shape” or “C-shape” [KOLAR P, 2014].

1.2.5.2 Patellar mobilisation

Proper mobility of the kneecap is important for ideal knee joint function. Hypomobility of patella is common after TKA, but mobilisation techniques can be performed to increase the mobility and improve or restore function of the patellofemoral joint. Caution should be taken in patients with hypermobility or history of patellar dislocation. During examination the PT will try to detect unevenness, resistance and roughness when trying to slide the patella over the structures lying below. Mobilisation of patella may be utilized in laterolateral and craniocaudal direction, and also circular movements against the underlying structures [CLAY J.H, POUNDS D.M, 2003].

1.2.6 Psychological and social aspects after TKA

In the preparation for the TKA it is important to correctly inform the patient about the procedure, the possible complications and the period after the surgery, in regard to what to expect and how to go forward. This is necessary to help improve the psychological state of the patient and make them more able to handle the post-operative challenges. If the patient has a positive approach it will increase the chances of successful rehabilitation and a faster return to daily activities. Pain is a subjective feeling and it will occur after such surgery, although remedies to somewhat “control” the pain is given. Hence, the mindset of the patient will play a big part when it is sometimes necessary to exercise through the pain. A positive and motivating PT may also play an important role [PORTER S, 2017]. After discharge 34

from the hospital, the patient need to continue home care on their own, and this may be more psychologically challenging in a situation where the individual live alone or have a small social circle. In this case it would be more beneficial, both psychologically and physically, to have someone considered close to help, not to be too isolated from the surroundings. A healthy social environment will increase the motivation and quality of life and make it easier to overcome post-operative challenges [BATARFI M.A et al, 2018].

2 CASUISTIC

2.1 BASIC DATA

Name of the patient: D.V.

Age: 75

Height: 182 cm

Weight: 78 kg

BMI: 23,5

Sex: Male

Blood pressure: 130/60

Heart rate: 67 beats per minute

Department in which the patient was hospitalized:

Department of Rehabilitation and Physiotherapy MF MU

Period of hospitalization:

Date of admission to orthopaedics: 2.11.2017. Mr. D.V. with left knee arthritis was admitted for TKA implantation.

Date of discharge from orthopaedics: 10.11.2017. The patient was educated about postsurgical regime, rehabilitation and care, prevention of thromboembolic diseases and possible postsurgical complications. Healing of the wound without complications, but still with stiches. Mr. D.V. felt well and did standardized exercises, and even walked with underarm crutches without assistance, subjectively without difficulties.

Date of admission to inpatient rehabilitation: 16.11.2017.

Type of surgery:

TKA I.sin. Sigma, A-P implantation on 3.11.2017.

Medications:

Lyrica 75mg 1-0-1, Benfogamma 0-0-1, Paralen 500 mg 2 pastrils max. a 6 hour, Pradaxa 110 mg 0-0-2, Aescin 2-2-2, Tramal 50mg 1-1-1

2.1.1 Case history

Current illness:

Pain of both knee joints with worsening of symptoms last year of the left knee, even though conservative treatment- he was referred to orthopaedics for TKA implantation. No contraindications for surgery.

Personal history:

Mr. D.V have had quite many injuries throughout his life. In a skiing accident in 1967 he ruptured his ACL and lateral collateral ligament in his left knee. In 1977 he underwent surgery for hemopneumothorax due to a broken rib which penetrated his lung. An unsuccessful ear operation in 1980 lead to decreased hearing on his left ear. He ruptured his right biceps during a heavy concrete pull, fractured his left shoulder blade in a car accident, and In 2016 he had arthroscopy of the left knee. In the beginning of 2017 he had luxation of his left shoulder and paresis of the brachial plexus.

Family history:

His mother passed away in ovary cancer, his grandmother in breast cancer and grandfather in hepatic cancer. 37

Work history:

Mr. D.V. retired from work 15 years ago. In the beginning of his working life he started as a machine engineer in Brno, where he produced medical equipment. From 1982, Mr. D.V. worked in Austria as a machine engineer producing and selling chemical equipment.

Social history:

Mr. D.V. enjoys sports, especially ball sports such as tennis, football, basketball and volleyball. He competed in his younger age but not at a professional level. He also trained children in skiing. Nowadays he mostly plays golf and do cross country skiing. He lives together with his wife in their house which has a few stairs.

Allergies:

No known allergies.

Pharmacology:

No regular medications other then what was received during his hospitalisation.

Substance use:

Mr. D.V. does not smoke and only drink alcohol occasionally on social events. No other drugs are used.

Physiological functions:

Appetite, urination and defecation is normal, and he sleeps well.

2.1.2 Diagnosis at admission

M171 Gonarthritis I.sin.

2.2 EXAMINATION

2.2.1 Kinesiological examination of the patient

Aspection:

From frontal view, hammer toes and hallux valgus can be seen on both sides, with higher severity on the operated side. Flat foot of transversal arch, dry skin on legs, and left spina iliaca anterior superior is located higher. On his right leg the quadriceps muscle seems to be contracted because he tries to maintain balance weight bearing, avoiding any on the operated side. On his left leg patella is hidden due to swelling and quadriceps muscle seems to be relaxed. The skin is darker on the operated side around the knee. The scar is s-shaped and runs along the middle of the knee. Left shoulder is elevated.

From posterior view, it can be seen that angulus inferior of right scapulae is more prominent and spina iliaca posterior superior is located higher on the left side, as well as the subgluteal and knee fold. The left side gluteal muscle is hypotonic and left side Achilles tendon is thicker than the opposite side.

From the left side view, right side flat foot and slight flexion of the knee joint on the operated side can be seen.

Palpation:

On the operated side was found increased temperature around the site of surgery, also there was a significant swelling, stiffer skin and decreased patellar movement. The scar was stiff and had low mobility.

Gait assessment:

Mr. D.V uses three-point gait and underarm crutches. He was leaning towards the right side and his left shoulder was elevated. He was moving with constant flexed knee in the operated side.

AROM goniometry:

- In table 1 there are AROM measurements of hip, knee and ankle.

TAB 1. AROM GONIOMETRY

Right Left (operated) HIP S: 10-0-110° S: 10-0-90° (supine position) F: 35-0-20° F: 35-0-20° KNEE (prone position) S: 0-0-110° S: 0-0-70° ANKLE (seated position) S: 10-0-65° S: 5-0-60°

Circumference measurements:

- In table 2 there are circumference measurements of thigh, knee and calf.

TAB 2. CIRCUMFERENCE MEASUREMENTS (cm)

Right Left (operated) THIGH 42,5 46,5 KNEE 40,5 46 CALF 37 38

Movement stereotype testing:

- Shoulder abduction in seated position: The movement on left side is possible but not fluently performed, left scapula is located in a higher position.

- Flexion of the trunk in supine position: Without problem

- Flexion of the neck in supine position: Without problem

- Extension of the hip in prone position: Left side following activation chain- hamstrings-gluteus-homolateral extensors of lumbar back.

- Hip abduction in side lying position: Performed on both sides in combination with hip flexion.

Dynamometer test:

- In table 3 there are measurements by dynamometer of quadriceps muscle strength through isometric contraction.

TAB 3. DYNAMOMETER TEST

Right Left (operated) Newton (N) 448,6 155,9 Newton meter (Nm) 210,84 73,27

FIG 5. EXAMPLE OF DYNAMOMETER MACHINE FOR TESTING OF

QUADRICEPS MUSCLE STRENGHT THROUGH ISOMETRIC CONTRACTION

Picture taken from ResearchGate.net.

(https://www.researchgate.net/figure/Realization-of-isokinetic-dynamometry-maximum-vol untary-isometric-contraction-MVIC-of_fig1_261518674)

2.2.2 Manual muscle test Manual muscle test is a method used to assess muscle strength. There are 6 grades: Grade 0- No visible or palpable contraction, grade 1- Visible or palpable contraction, grade 2- Full ROM without gravity, grade 3- Full ROM against gravity, grade 4- Full ROM against gravity with moderate resistance, grade 5- Full ROM against gravity with maximum resistance [KENDALL P.F et al, 2010].

TAB 4. MANUAL MUSCLE TEST

Muscle: Movement: Position of the Left side Right side patient: grading grading: (operated): M. iliopsoas Hip flexion Supine 5 5 M. gluteus Hip abduction Side lying 4 5 medius Mm. adductori Hip adduction Side lying 4 5 M. quadriceps Knee extension Supine 4 5 M. gluteus Hip joint Prone 4 5 maximus extension minus Hamstrings Knee joint Prone 4 5 flexion minus M. Plantar flexion Prone 4 5 gastrocnemius (extended knee) M. soleus Plantar flexion Prone 4 5 (flexed knee) plus M. tibialis Inversion in Supine 5 5 anterior dorsal flexion M. fibularis Eversion Supine 5 5

2.2.3 Muscle shortening test

- In table 5 are muscle shortening test of lower limbs. This test is used to assess shortened muscles.

Grade 0- No shortening

Grade 1- Little shortening

Grade 2- Big shortening

TAB 5. MUSCLE SHORTENING TEST

Muscle: Left side grading Right side grading: (operated): M. iliopsoas 0 0 M. rectus femoris 1 0 Hamstrings 1 0 Adductors 0 0 M. triceps surae 1 0

2.3 SHORT-TERM REHABILITATION PROGRAM

Mr. D.V. stayed at orthopaedic department for short-term rehabilitation post-surgery. This was his day by day rehabilitation and progression:

3.11.2017- Day of surgery, no rehabilitation, only positioning of the knee joint in flexion-extension and cryotherapy.

4.11.2017- Beginning of kinesiotherapy in supine position, isometric exercise with muscles in lower limbs, active exercise with healthy limbs and respiratory physiotherapy.

5.11.2017- Positioning, cryotherapy and self-exercise. Sitting at the bed- with extended lower limbs.

6.11.2017- Kinesiotherapy in supine and seated position. Active-assisted knee flexion to 60°, assisted hip abduction and flexion, standing and walking short distance with under arm crutches with PT.

7.11.2017- Mr. D.V. continued with current rehabilitation and walked on his own.

8.11.2017- Assisted knee flexion to 70°.

9.11.2017- Climbing stairs with assistance of PT.

10.11.2017- Climbing stairs again and AROM- extension 0°, flexion 70°.

After this Mr. D.V. was discharged and then came back at 16.11.2017 to inpatient rehabilitation department where the author continued the rehabilitation.

2.3.1 Realization of rehabilitation

16.11.2017

Full anamnesis of the patient was taken as well as the basic data was written up.

17.11.2017

Kinesiological examination, manual muscle testing, testing of shortened muscles and movement stereotype testing was done (see chapter 2.1.3, 2.1.4, 2.1.5).

18.11.2017

We started with some exercise in supine position with toes and ankles doing dorsiflexion and plantarflexion, ankle pumping in circles. Then we worked with AROM in the knee joint doing flexion and extension without equipment and with equipment such as over ball and exercise ball. We started with closed kinetic chain and then continued with open kinetic chain. Mr. D.V. was not bothered with pain and in good condition, so we could exercise without interruption. We did isometric contraction of m. quadriceps, m. tibialis anterior, m. gluteus maximus and m. triceps surae. In the hip we worked with flexion and abduction in supine position. Because of Mr. D.V. was in good state we could proceed with a few more advanced exercises with combinations of hip, knee and ankle joint at the same time. Mr. D.V. could by himself do stretching of hamstrings with extended knee using the band.

19.11.2017

After exercising in supine position doing circulatory exercises, we did a few exercises in prone position working with the flexion and extension in the knee joint and extension in the hip joint. After prone position we went into seated position on the big exercise ball doing sensory motoric exercises. We combined several of the

exercises with other equipment such as rubber band, dumbbell and over ball. We finished our session with introducing the motomed bicycle, Mr. D.V. cycled for 5 minutes with low load, he completed the whole exercising session without pain.

20.11.2017

We started the session in supine position doing strength exercises for lower limbs, also in synkinesis with upper limbs. After that we went into side lying position doing proprioceptive neuromuscular facilitation (PNF) for M. quadriceps on the operated side, trying to improve the degree of knee joint flexion. We then went to seated position to do some exercises for extension in knee joint and flexion in hip joint and dorsiflexion of the foot. After the exercise Mr. D.V. was lying down in supine position for 20 minutes with a pillow under the heel to improve the extension of the operated knee.

21.11.2017

We did some exercise in seated position sitting on the exercise ball to work more with the stabilisation, then we continued with gait training. After our exercise session we went to practise stair climbing, going up and down the stairs a few times for Mr. D.V. to manage with proper and safe technique. Mr. D.V. then finished with 5 minutes on motomed bicycle.

22.11.2017

We started with 7 minutes on motomed bicycle. We then advanced with some exercises in standing position working with the postural muscles. After exercise was complete, cryotherapy (nitrogen) was applied for 4 minutes.

23.11.2017

I performed patellar mobilisation techniques on the operated side in the beginning of the session. Then we did gait training working with proper technique improving details, and we completed the session with training of stair climbing.

24.11.2017

We started the session with me performing scar mobilisation techniques on Mr. D.V. Then we continued with exercises in supine, prone, seated and standing position. We completed the session with a 4-minute application of cryotherapy (nitrogen).

28.11.2017

The kinesiological examination and assessment of the patient at the completion of comprehensive rehabilitation was done and evaluation of Mr. D.V.s progression during his stay at rehabilitation department.

All the exercises during our rehabilitation period were done with proper controlled breathing, technique and variety to keep Mr. D.V. focused and motivated throughout the session.

2.4 KINESIOLOGICAL EXAMINATION OF THE PATIENT AT THE COMPLETION OF COMPREHENSIVE REHABILITATION

Aspection:

From frontal view can be seen hammer toes and hallux valgus on both sides but worse on operated side, flat foot of transversal arch, dry skin on legs, left spina iliaca anterior superior is located higher. The skin is darker on the operated side around the knee. The scar is s-shaped and runs through the middle of the knee. Left shoulder is slightly elevated.

From posterior view can be seen that spina iliaca posterior superior is located higher on the left side, so is also the subgluteal and knee fold. Achilles tendon is thicker than the opposite side. Angulus inferior of right scapulae is more prominent.

From the left side view can be seen right side flat foot.

Palpation:

In comparison of before and after rehabilitation in the operation site was found decreased temperature, more mobility in the skin, greater patellar movement and reduced swelling.

Gait assessment:

Mr. D.V. walks in a more upright position with increased flexion/extension movement in the operated knee in comparison to the first assessment. Mr. D.V. uses underarm crutches and three-point gait.

AROM goniometry:

- In table 6 there are measurements of AROM goniometry of hip, knee and ankle. There can be seen improvement of left hip AROM in sagittal plane by 30° and left knee AROM in sagittal plane by 20° after completed rehabilitation.

TAB 6. AROM GONIOMETRY

Before rehabilitation: After rehabilitation: Right Left (operated) R L HIP S: 10-0-110° S: 10-0-90° S: 10-0-130° S: (supine F: 35-0-20° F: 35-0-20° F: 35-0-20° 10-0-120° position) F: 35-0-20° KNEE S: 0-0-110° S: 0-0-70° S: 0-0-110° S: 0-0-90° (prone position) ANKLE S: 10-0-65° S: 5-0-60° S: 10-0-65° S: 5-0-60° (seated position)

Circumference measurements:

- In table 7 are circumference measurements of thigh, knee and calf. The table shows decrease in circumference around the operated knee by one cm because of reduced swelling.

TAB 7. CIRCUMFERENCE MEASUREMENTS (cm)

Before rehabilitation: After rehabilitation: Right Left (operated) R L THIGH 42,5 46,5 42,5 46,5 KNEE 40,5 46 40,5 45 CALF 37 38 37 38

Dynamometer test:

- In table 8 there are measurements by dynamometer of quadriceps muscle strength through isometric contraction. The table shows significant increase in power of both lower limbs after rehabilitation was completed.

TAB 8. DYNAMOMETER TEST

Before rehabilitation: After rehabilitation: Right Left (operated) R L Newton (N) 448,6 155,9 527,5 218,4 Newton 210,84 73,27 247,92 102,65 meter (Nm)

Manual muscle test:

- In table 9 (on the next page) are results from manual muscle test, which was used to assess muscle strength in several muscles of importance after TKA. The table shows that after the completed rehabilitation there was improvement in muscle strength on both lower limbs.

TAB 9. MANUAL MUSCLE TEST

Before rehabilitation: After rehabilitation: Muscle: Movement: Right side Left side R L grading: Grading(op.)

M. iliopsoas Hip flexion 5 5 5 5 M. gluteus Hip 4 4 5 5 medius abduction Mm. adductori Hip 4 4 5 5 adduction M. quadriceps Knee 4 4 5 5 extension M. gluteus Hip joint 4 4 4 4 maximus extension minus plus plus Hamstrings Knee joint 4 4 4 4 flexion minus plus plus M. Plantar 4 4 5 5 gastrocnemius flexion (extended knee) M. soleus Plantar 4 4 5 5 flexion (flexed knee) M. tibialis Inversion in 5 5 5 5 anterior dorsal flexion M. fibularis Eversion 5 5 5 5

Muscle shortening test:

- In table 10 are results from muscle shortening test. The table show improvement in hamstrings and M. triceps surae of the operated leg after rehabilitation.

Grade 0- No shortening

Grade 1- Little shortening

Grade 2- Big shortening

TAB 10. MUSCLE SHORTENING TEST

Before rehabilitation: After rehabilitation: Muscle: Right Left side R L side grading: grading (operated): M. iliopsoas 0 0 0 0 M. rectus femoris 0 1 0 1 Hamstrings 0 1 0 0 Adductors 0 0 0 0 M. triceps surae 0 1 0 0

2.5 LONG-TERM REHABILITATION PROGRAM

In the long-term aspects after TKA it is important to continue the exercise program also after being discharged from the hospital, because the process to full recovery after such surgery will take several months. It is important not to overuse the joint, therefor no extreme sports should be performed. However, moderate activity and exercise is crucial for full recovery. To keep a healthy diet is also of importance not to gain excessive weight and therefor put more stress on the joint. Some adjustments in the home environment may be necessary such as elevated toilet seat, anti-slide math and seat in the bath tub, walking aids or other devices that may assist the daily life. Help from friends and family may be of importance in the subacute phase, not only for the physical aspects but also for the psychological aspects, not to be completely excluded from surroundings and social interactions which may be of motivational importance of the individual. Spa treatments such as whirlpool may be beneficial for reducing the swelling, increase circulation and the well-being feeling. Depending on the type of work the individual will gradually return to the job as soon as possible, it is of high mental importance to have stimulation and a feeling of purpose for increased quality of life [KISNER C et al, 2012].

2.6 CONCLUSION

In the first part of my bachelor thesis I wrote about the topic of rehabilitation after total knee arthroplasty. I discussed the functional anatomy of the lower limb, definition of TKA, some of the most common indications for TKA and the surgical procedure of TKA. In the specialized part I described rehabilitation program after TKA, where an early post-operative start and consistent exercise regime have shown to be highly important in the process to full recovery, regular exercise seems to be crucial for a quicker return to daily life activities. I also in this part discuss the psychological aspects after such operation and the importance of a motivated mind of the patient, which plays a huge role when it comes to execute the exercise program prescribed from the PT.

In the second part I have also described a case study of a patient after TKA from inpatient department. This was for me an opportunity to use my gained theoretical knowledge and put it into practical work and get a unique insight in the rehabilitation process after TKA with a patient. During my work with the patient I performed an anamnesis, kinesiological examinations, muscle tests and completed a rehabilitation program. This thesis has enriched my theoretical knowledge and given me a deeper understanding in the rehabilitation process after TKA. This work has also given me the experience in practical one on one cooperation with a patient which will be valuable in my future work as a physiotherapist.

3 REFERENCES

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APPENDIX I

Mr. D.V. before rehabilitation. Photo is taken by the author with Mr. D.V.s approval to use in this thesis.

APPENDIX II

Mr. D.V. after rehabilitation. Photo is taken by the author with Mr. D.V.s approval to use in this thesis.