Patient Needing Total Knee Arthroplasty (TKA)

Patient Needing Total Knee Arthroplasty (TKA)

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A total knee arthroplasty is indicated for an effective way to treat late stage arthritis in the knee. According to Trojani et alˡ two thirds of the patients who have a total knee arthroplasty (TKA) have the degenerative disease in both knees. Twenty percent of those patients will have to have surgery on the other knee within two years of having the first surgery.ˡ When the disease affects both knees the patient only benefits when both knees joints are replaced. With the appropriate patient, an orthopaedic surgeon may elect to do a simultaneous bilateral total knee arthroplasty where the patient undergoes a total knee replacement on both knees at the same time. This means the patient only has to undergo one surgery.

According to Patil et al² having both knees replaced under one anesthetic as compared to having two separate surgeries has many benefits. The benefits include limiting an invasive surgical procedure with anesthesia to one event while the patient has symmetrical rehabilitation of bilateral knees which will reduce hospital stay and ultimately the hospital costs that come with the surgery.² Some patients if appropriate elect to have a simultaneous bilateral total knee arthroplasty due to the advantages of having a single hospital stay, only having to undergo anesthesia once, and a shorter rehabilitation. Studies have shown there are more risks for medical complications during and after surgery for patients who undergo a bilateral total knee arthroplasty, but some believe the advantages far outweigh the risks.

A total knee arthroplasty can give a patient an increased overall quality of life with improved functional mobility and reduced pain. However, following a TKA a patient will have strength and functional deficits as well as decreased mobility. A patient will need physical therapy in order to return to their prior level of function.

There seems to be no established standard or protocol for rehabilitation after a total knee arthroplasty. Studies have looked at strengthening exercises, aquatic therapy, and balance training to increase functional mobility following a single total knee arthroplasty. According to Pozzi et al³ studies show progressive exercise is imperative for patients recovering from a TKA due to a large decrease in quadriceps strength immediately following a knee replacement surgery. Studies have also shown that patients following a TKA are at a higher risk for falling. Therefore balance impairments should be a focus of physical therapy treatment along with increasing range of motion in the involved extremity.

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Studies have shown aquatic therapy is a great way to reduce the stress and weight on the joint after a knee replacement while providing resistance for strengthening as long as the incision site has completely healed.

A review of the literature related to the physical therapy treatment of patients who undergo a bilateral total knee arthroplasty is limited. The physical therapy treatment of a patient who has undergone a simultaneous bilateral total knee arthroplasty is similar to the treatment of someone who has undergone a single total knee arthroplasty except the patient and therapist have double the work to gain the strength and range of motion back in both lower extremities. Since most of the literature focuses on a single total knee arthroplasty, the purpose of this case report is to describe the physical therapy plan of care for a patient who underwent a simultaneous bilateral total knee arthroplasty. The patient’s plan of care was followed and administered by a physical therapy student for six weeks during the student’s eight week clinical rotation while being supervised by a licensed physical therapist at an outpatient clinic.

Patient History
The patient is a 64 year old white male who had a simultaneous bilateral total knee arthroplasty, secondary to severe osteoarthritis. He had an extended history of bilateral knee pain and attributed the arthritis to playing sports when he was young. He described a sharp, constant pain in both knees prior to surgery. The patient was limited in his activities of daily living (ADL) due to severe pain and decreased knee range of motion (ROM). His professional duties as a paint contractor were also limited due to pain when getting in and out of his truck, carrying gallons of paint, squatting, and walking on job sites. He stopped all recreational activities due to pain and limited ROM. Previously his hobbies included working out at the gym and scuba diving.

After many years of dealing with pain in both knees, he decided to have both knees replaced at the same time, not wishing to be put under anesthesia twice. The convenience of getting both knees replaced at the same time persuaded him to go ahead with the surgery. The patient’s surgery took place on July 12, 2013. After his surgery, he was discharged home with home health. He participated in therapy through home health for four weeks. Five weeks post-op, he was referred by his orthopaedic surgeon to an outpatient clinic for bilateral knee pain.

Initial Physical Therapy Examination

Presenting Complaint
At the time of the initial examination, five weeks after surgery, the patient arrived at the outpatient clinic ambulating with a single point cane for increased balance. The patient’s main complaints included pain that increased when sitting longer than ten minutes, pain upon static standing longer than five minutes, and pain upon walking greater than 45 minutes. The patient stated he was currently using handrails in order to ascend and descend stairs, but he avoided stairs if possible due to pain. His pain was averaging 4/10 with use of pain medications.

Functional Status
Prior to the examination, the patient completed the Lower Extremity Functional Scale (LEFS). The LEFS is a self-report questionnaire given before the evaluation in order to establish a baseline for the patient’s functional ability. Then the patient was given the LEFS upon his last day of treatment during the student’s eight week clinical session for an outcome measure in order to show the patient’s progress. It consists of 20 questions asking about the patient’s ability to perform everyday tasks. Binkley et al4 have reported the LEFS to be valid, reliable, and sensitive to change. On the initial LEFS, the patient scored 54/80 equaling 68%, indicating his maximal function.

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