Chapter 10: Total Knee Arthroplasty: Current Concepts in Physical Therapy Management 3 Contact Hours
By: Diane M. Heislein, PT, DPT, OCS Learning objectives
After completing this course, the learner will be able to: Describe the epidemiological trends for total knee arthroplasty. Explain the anatomical components of the knee and how degenerative changes may influence the need for knee replacement surgery. Identify the indications for total knee arthroplasty, as well as preoperative planning and rehabilitation. Course overview The knee is the most common site of painful osteoarthritis (OA) in people over the age of 45. When degenerative changes in the knee joint cause progressive pain and significantly impair mobility, a knee replacement may become necessary to restore functional ability and quality of life. Knee replacement surgery provides significant pain relief and restoration of functional mobility in patients with end-stage knee OA, with up to 90% of patients expressing satisfaction with their surgical outcomes (Singh & Lewallen, 2014). Knee replacement surgery may be indicated in patients who have significant degenerative changes in the joint associated with conditions such as primary and secondary OA, rheumatoid arthritis, osteonecrosis, or joint destruction associated with osteomyelitis. The most frequent preoperative diagnosis for total knee arthroplasty is end-stage OA, which causes pain, joint instability, and impaired function. In the United States, total knee arthroplasty is one of the most common elective surgical procedures with more than 700,000 procedures performed each
Summarize the surgical approaches to total knee arthroplasty and potential complications and how they may impact rehabilitation and recovery. Discuss postoperative physical therapy interventions and expected outcomes following total knee arthroplasty. Describe future considerations in delivering care to patients following total knee arthroplasty. year (Healthcare Cost and Utilization Project, 2015). Research is ongoing, but most experts contend that for the most successful postoperative outcome, rehabilitation is an essential component of recovery. The purpose of this intermediate-level course is to provide physical therapists and physical therapist assistants with a comprehensive overview of the many considerations surrounding knee replacement surgery, including the relevant anatomy, epidemiology, patient selection criteria, surgical considerations, common postoperative complications, and rehabilitation strategies. This course discusses pre- and postoperative patient management, rehabilitation goals, and treatment in the acute, post-acute, and functional recovery stages. This course, which is relevant for physical therapists and physical therapy assistants, provides evidence-based research that supports rehabilitation treatment methods and outcomes following total knee arthroplasty while highlighting the areas in need of further study.
EPIDEMIOLOGY
Total knee replacement surgery, also known as total knee arthroplasty (TKA), is a successful and cost-effective way for patients to regain quality of life from debilitating osteoarthritis (OA; da Silva, Santos, Junior, & Matos, 2014; Ruiz, 2013). The purpose of the surgical procedure is to improve health- related quality of life by enabling patients to enjoy increased mobility and participation in activities of daily living (ADLs), with decreased pain (Singh, 2014). More than 730,000 knee replacement surgeries were performed in the United States in 2013, with an increasing trend in surgeries occurring in adults under the age of 65, who are at an increased risk of needing a revision procedure in their lifetime (Healthcare Cost and Utilization Project, 2015; American Association Orthopaedic Surgeons [AAOS], 2015; Weinstein et al., 2013). It is estimated that in 2010, 4.7 million adults were living with a total knee replacement in the United States, representing 4.6% of the population over the age of 50, with the greatest growth in prevalence occurring in older women (Kremers et al., 2015). On average, women are older than men at the time of surgery and show greater functional impairment, with the differences in functional mobility scores persisting postoperatively (O’Connor, 2011; Parsley, Bertolusso, Harrington, Brekke, & Noble, 2010). Racial disparities exist in the utilization of TKA with lower rates of surgery in African Americans and Hispanics compared to whites even when accounting for a variety of socioeconomic and personal values (Collins, Deshpande, Katz, & Losina, 2015; Shahid & Singh, 2016).
Osteoarthritis is the most common preoperative diagnosis for TKA and the demand for primary knee arthroplasty procedures continues to rise each year (Cram et al., 2012; Kurtz, Ong, Lau, Mowat, & Halpern, 2007; Kurtz et al., 2009). OA of the knee is prevalent, with radiographic evidence of degenerative joint disease in approximately 50% of patients age 75 years or older (Suri, Morgenroth, & Hunter, 2012). The risk factors associated with the development of knee OA include obesity, female gender, previous knee trauma, presence of hand OA, and older age (Blagojevic, Jinks, Jeffery & Jordan, 2010). For many of these individuals, a knee replacement is indicated when nonsurgical interventions, including medication, activity modification, weight loss, physical therapy for exercise, bracing and other biomechanical modification, and/or use of an assistive device for ambulation do not provide sufficient pain relief for their desired activity participation. TKA surgery has traditionally been reserved for patients over the age of 65 to reduce the incidence of revision surgeries (Julin, Jämsen, Puolakka, Konttinen, & Moilanen, 2010). In general, the number of TKA surgeries is on the rise, with patients younger than age 65 now comprising one-third of all primary (first-time) TKA surgeries (Khatod et al., 2008; Ravi et al., 2012). Increasingly, younger patients are seeking TKA as a means to continue their physically active lifestyles despite the presence of severe OA or rheumatoid arthritis (RA), and studies examining survival rates of the prosthetic implants in this cohort are yielding mixed results (Aggarwal et al., 2007; Bisschop, Brouwer, & Van Raay, 2010; Kim, Kim, Choe, & Kim, 2012; Roberts,
Book Code: PTNY3622B
Page 157
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