TKA Question

[Krazykritter]

Hi all,

Just a quick question about a TKA. My father is having his right knee replaced by a surgeon I know fairly well & am fully confident in his abilities. He is 54 yo, in excellent health (I would be delighted to be in as good shape as he is at 40 let alone almost 55) & currently can only flex his knee to about 100 degrees. Since I am only an M2 & have not had ortho yet, what kind of ROM improvements you can usually expect for someone w/ that much of already restricted motion?? I know it can vary from case to case, but would appreciate any insight. Thanks.

Just to clarify, the only reason he has approved for the TKA was he failed the Synvisc injection regimen & has so much constant pain that it was deemed appropriate.

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[Orthodoc40]

I'm pretty sure a lot of it depends on how diligent he is with his rehab, especially in the earliest phase. But what do I know...

 

[hammena1]

Many people tell patients that replacements are for pain relief only and range of motion in is the best possible range of motion out.

 

[robe25]

I think most surgeons would be happy getting 100 degrees of flexion post op in most patients but it depends on the rehab and stretching afterward. Functionally that is all that is really needed in a society that uses chairs.

 

[DOctorJay]

I'm a PT who is currently a med student and continues to work as a per diem therapist. I routinely eval and treat knees post op and can tell you that our goal for most patients s/p TKA is ROM from full extension (zero degrees) to about 90-100 degrees of flexion - we are happy to D/C pts when they reach 90 but expect a few more degrees during out patient therapy.

Make sure your dad participates fully in his rehab and he should do quite well.

Finally, I understand your concerns regarding flexion but full extension is actually much more important for functional ambulation and a noramlized gait pattern (so no pillows under the knee at night and work those quad sets with the therapists!).

J

 

[Krazykritter]

DOctorJay,

Thanks for the reply. When I said 100 degrees of flexion, I was meaning the angle btwn Upper Leg & Lower Leg in flexion. Regardless, my father is actually a very compliant patient in all regards except pain meds (he thinks he is tough) but I have been on him already about making sure that he takes his pain meds so that he can put the amount of effort into the rehab that he should w/out being in debilitating pain.

I will have to relay the no pillows thing. Thanks again for your input.

 

[DOctorJay]

DOctorJay,

Thanks for the reply. When I said 100 degrees of flexion, I was meaning the angle btwn Upper Leg & Lower Leg in flexion. Regardless, my father is actually a very compliant patient in all regards except pain meds (he thinks he is tough) but I have been on him already about making sure that he takes his pain meds so that he can put the amount of effort into the rehab that he should w/out being in debilitating pain.

I will have to relay the no pillows thing. Thanks again for your input.

yup, I'm with you on the flexion thing, that's what I was talking about also.

 

[SOUNDMAN]

I would totally agree about obtaining full extension as one of the most important things with the TKA. The surgeons I was working with really expected about 110 degrees actually out of all of their TKA's. However many times as in this case, if you don't have that before the surgery, you may be unlikely to achieve it afterwards, again pain relief is the primary goal once all conservative treatment has been exhausted.

Also being young like your father is, there may be the higher incidence of having to undergo a revision surgery in the distant future due to the poly (plastic bearing) wearing out, or other issues.

The physicians I worked with believed 110 degrees was the magic number because at that point a person can "usually" go down a flight of stairs one foot after the other and not have to go down one foot at a time...just some ROM for thought

Good luck to him, it's a great surgery and like DOctor Jay said "NO PILLOWS under that knee!!"

 

[2nd year]

Like "DocJay" I too am a PT and am still working as a PT while in Med. school. I have a lot of experience with post-op TKA pts and I'll tell you that many factors play into the amount of motion your old man can expect after surgery. Research indicates that by far the best predictor of ROM after surgery is ROM before surgery. I think that this is probably true. However, there are many other factors that will make a big difference. First of all, don't choose a surgeon because he is a family friend or because he is just a good guy. Neither of these things are going to help your Dad's knee. There is a difference between surgeons and their outcomes are pretty consistent. Find out who does the most TKAs anually in your area. Most areas have a few guys who do far more than the rest of the local Orthopods. These are generally your "go to docs." Secondly, make sure that the surgeon has a good rehab plan in place. His rehab should begin early and it should be aggressive. 90 degrees is a very reasonable goal for the end of the first week. If he has a good surgeon, a good therapist and the necessary motivation and compliance, there is no reason that he shouldn't achieve this. It is painful to bend your knee after TKA surgery, but afterall, they are replacing his knee. My ultimate goal would be no less than 100 degrees if this is what he has now. He may even get more than that. Most of my pts end up around 110-120 and I'm pretty stingy with the goniometer. Bottom line, flexion takes work and a little bit of pain tolerance. My best advice as far as getting that flexion is to emphasize to your Dad to actively bend his knee. Let the PT help push him, but don't resist the therapist's force. Work with him. If he is resisting, he'll only swell more and the pain and effort will be counter-productive. Don't settle for 90 degrees. People always point out that this is all you need to sit comfortably in a chair. Give me a freaking break. Your Dad isn't having his knee replaced so that he can sit comfortably in a chair.
As far as extension goes, achieving this can be as painful or even more painful than flexion. The nice part about extension is that if he is a diligent patient, he can achieve most of this on his own without a therapist cranking on him. While he ices his knee, have him rest with the leg elevated and keep something under his heel/ankle/calf, but not under the knee. The ice should be on top of the knee weighting it down somewhat. Toes pointed toward the ceiling, i.e, don't let him externally rotate at the hip. Then tell him to let the knee relax as gravity pulls it into extension. Once he can tolerate this, he should actively work at contracting his quads to actively force it into extension. Quad sets are mindless and require little energy. He should be doing them early and often and he certainly doesn't need a therapist present to do so.
Best of luck. This is a great surgery when the pt. is willing to put the work in. Take care.

 

[PT2MD]

Hey all. First time posting on this board. I've been treating TKA for nearly 5 years. I consider a good outcome between 110-115 degrees of flexion. Any more is great. As long as they are close to 110 (and are able to produce muscular force at that angle - like in a sit to stand), the patient should be pretty stoked with the results. The pain relief seems to be the biggest upside from the patients' standpoint. Good luck and I hope his recovery goes well.