desire or require greater physical activity after surgery. However, the downside to the high tibial osteotomy is a long recovery time, as the osteotomy site needs to heal prior to resuming normal activities. As a physical therapist, it is important to be aware that knee realignment may be appropriate for younger, Knee arthroplasty Knee arthroplasty is the “last resort” surgery for patients with knee OA. This is an invasive procedure in which all or part of the cartilage and subchondral bone is removed from the tibia and femur and is replaced by metal and polyethylene components. Although the purpose of this course is not to describe the physical therapy evaluation and treatment for patients undergoing knee arthroplasty, it is important to understand the patient characteristics that may make someone an appropriate candidate for a partial or total knee arthroplasty surgery. Understanding these concepts will help the physical therapist make informed decisions about continuing or discharging patients from supervised physical therapy services or referring them to appropriate health professionals for further evaluation. There are two main types of knee arthroplasty, partial and total knee arthroplasty, which will be discussed in the next sections. Partial knee arthroplasty Younger patients who have knee OA that is isolated to one compartment and no other major joint injuries may be candidates for a partial knee replacement. In this procedure, only one half of the knee joint is replaced, either the medial or the lateral tibiofemoral compartment. This surgery has advantages over TKA because it requires less cutting of the bone, cartilage, and soft tissue. This makes the recovery time quicker and functional outcomes better than TKA. If the patient requires additional knee surgeries in the future, there is more bone stock within the joint because only half of the joint is reconstructed. Although recovery and outcomes may be better than TKA, it is not common that OA develops and is isolated to only one joint compartment. Unicompartmental knee OA is usually the result of posttraumatic OA rather than the typical age-related degenerative condition. Patients who have experienced trauma, such as a fracture, ligament injury, or chondral defect, are likely Conclusion Knee osteoarthritis is a common, debilitating condition that affects millions of Americans. There are limited treatment options to combat the symptoms and impairments associated with knee OA, but physical therapy repeatedly has been shown to reduce symptoms, improve function, and reduce disability for this patient population. When evaluating patients with knee OA, the physical therapist should always include performance- based measures of function and self-reported questionnaires. Identifying the concomitant impairments, such as knee instability, muscle weakness, joint swelling, malalignment, and sedentary behaviors, will help to guide patient treatment. Because not all patients with knee OA present with the same symptoms, deficits, or goals, rehabilitation should be tailored to each patient. Although there have been many observational studies of patients with knee OA, there is a lack of literature evaluating the History: A 40-year-old woman presents to your outpatient physical therapy clinic with knee pain on her right side. This pain has been present for 15 years, but has only gotten worse in the past year. She was in a motorcycle accident at the age of 25. During the accident, she was thrown from the motorcycle when she rear-ended a stopped car. She sustained a displaced tibial plateau fracture and was treated with a cast at the time of the injury. She was non–weight bearing for 3 months after the accident. Although she was able to return to work 6 months after the accident, she had residual pain (about 2/10) at rest that would get worse with running and walking long distances. Three years after the accident, her orthopaedic surgeon informed her that she had posttraumatic osteoarthritis (OA) of the right
active patients with malalignment in the frontal plane but only moderate radiographic knee OA. Referring these patients to an orthopaedic surgeon should be considered on a case-by-case basis.
to develop OA in an isolated region of the joint. However, this surgery is usually reserved for patients that only have cartilage deterioration and have normal supporting ligaments, menisci, and bone. It is rarely performed on patients who do not have a functional ACL. Because this surgery allows for quicker recovery and greater activity after surgery, this type of arthroplasty is most appropriate for younger patients who have knee OA isolated to one compartment of the joint. In addition, the ideal patient should not have substantial malalignment in the frontal plane and should not have joint instability that interferes with normal function. Given these constraints on patient selection, this surgery is appropriate for a small percentage of patients who present with knee OA. Younger, active patients who are not surgical candidates for partial knee arthroplasty may instead benefit from a supervised physical therapy program that reduces impairments and symptoms, with an eventual transition to a home program designed to maintain muscle strength and range of motion. Total knee arthroplasty TKA is reserved for patients who have exhausted other conservative treatment options or are not candidates for other surgical or nonsurgical interventions. In TKA, the tibial plateau is cut to the subchondral bone, as is a portion of the femoral condyles. The surgeon must carefully choose a prosthesis size that restores normal tissue tension, while allowing for unrestricted range of motion for flexion and extension. A physical therapist can play an important role for patients who are candidates or who are considering TKA. Before surgery, physical therapists should inform patients about the recovery process, provide realistic expectations for functional recovery, and can provide home or in-clinic “prehabilitation.” effects of individual or combined physical therapy interventions on long-term functional and symptomatic outcomes. Even fewer studies have evaluated whether physical therapy can reduce the need for surgery or joint arthroplasty. Current evidence suggests that improving muscle strength and increasing physical activity can reduce long-term deficits and potentially delay the need for surgical interventions. Physical therapists should focus on these deficits in the plan of care. It is also important to remember that this is a progressive disease for which there is no cure or treatment, and that no treatment has been shown to reverse cartilage damage. When patients are discharged from supervised physical therapy, it is essential to provide a home-based progressive exercise program to help combat the progressive nature of the disease.
CASE STUDY
knee. Her surgeon told her at the time that she was not yet a candidate for any surgical intervention, but may need a knee replacement in the future. She did not seek additional treatment for this condition until last month, when she visited her orthopaedic surgeon. He gave her knee corticosteroid injections and prescribed a course of physical therapy. She currently reports her pain is 1/10 at rest and 4/10 with walking more than 30 minutes. She stopped running 6 months ago because of the pain. She reports some relief from the injections. Her X-rays from her orthopaedic visit revealed radiographic evidence of knee OA in the medial and lateral tibiofemoral compartments (Kellgren-Lawrence Grade 3) and no OA in her patellofemoral compartment.
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Book Code: PTNC1023
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