Case presentation on Total Knee Replacement

Kavitha.V

Physician Assistant, Department of Orthopaedic surgeon, Kauvery Hospital, Hosur

Introduction

Knee replacement has evolved considerably over the past 100 years. In its earliest form, interposition arthroplasty was attempted to manage the most severe pathology of the knee using materials such as bursa, fascia lata, skin, and pig bladder, usually with very poor results. Until the 20th century, arthrodesis remained the treatment of choice for severe degenerative knee conditions.

Metallic interposition arthroplasty of the tibiofemoral joint has been evolving since the 1930s with the use of many different designs and materials. Modern total knee arthroplasty (TKA) was born when the importance of the patellofemoral articulation was recognized, and the patellar component was introduced in the 1970s.

A Total knee replacement, also known as total knee Arthroplasty, is a surgical procedure where the damaged surfaces of the knee joint are replaced with artificial components. This typical involves resurfacing the ends of the femur and tibia, and sometimes the patella (kneecap), with metal and plastic parts. It’s a common treatment for severe knee Osteoarthritis and other conditions causing chronic knee pain and limited mobility.

Why is TKR performed?

To relieve severe knee pain and improve the quality of life for individuals suffering from knee joint conditions that limit daily activities.

Criteria for TKR

  • Severe pain limiting activities of daily living
  • Significant knee deformity (e.g., Varus or valgus)
  • Failure of non- surgical treatment (medications, physical therapy, injections)
  • The primary reason is to relieve pain and improve function in knees severely damaged by arthritis, particularly osteoarthritis.

Case presentation

58 years’ female, admitted with complaints of severe pain over right knee joint.

History of pain over right knee for few years, which increased for 6 months

Unable to bend right knee joint and difficulty in sitting and standing

Past History

  • Total knee Replacement left knee done 5 years back.
  • Known case of Rheumatoid arthritis for 30 years, medications discontinued past 2 months
  • N/K/C/O-DM/HTN/BA

Examination

Patient Hemodynamically stable.

Patient is conscious, oriented, afebrile

BP-130/80mmHg/, PR- 114/min/, RR-20/min/ ,Tem-980F/

GRBS- 199mg/dl

SpO2-99% on RA

CVS- S1S2(+)/ RS-B/L AE (+)/ P/A-Soft/ CNS-NFND

Local Examination-

Right knee joint & leg:

Bony ankylosis of right knee in 100 of flexion, No patellar mobility, No DVND.

Bilateral hip, spine clinically normal, Active ankle toe movements (+), Distal pulses felt (+)

Investigations

InvestigationsResult
Hemoglobin10.49 g/dl
Platelets550900 Lakhs/cumm
INR1.15
PTT11.0 sec
Potassium4.3
Sodium141
Blood Group‘A’ Positive
SerologyNegative
CRP54.9 mg/l
ESR107mm/hr
Creatinine0.54 mg/dl

Pre Op X-Ray

Loss of joint space

Final Diagnosis

  • Bony Ankylosis Right Knee (Rheumatoid Arthritis)

Procedure: Total knee Replacement right side with Quadriceps plasty done.

Under Spinal anaesthesia, Patient is on supine position, through, quadriceps snip approach arthrotomy done. Adhesions in retropatellar, suprapatellar area & both gutters were completely releases. Joint line identified & osteotome inserted in a progressive manner with glute hence flexion, until 900 of flexion is achieved. Distal femur cut of 9mm with 30 valgus done. Proximal tibial cut of 8mm done. Extension gap balancing done. Femur sizing done. 4 in 1 cut block inserted, post condylar, anterior femur & change cuts completed. 125mmx12mm femoral stem preparation done for 13mmx90mm tibial stem. Patella Preparation done & size to 3mm pulse large given. Femoral component of size 1.5 with 125mm stem inserted & tibial component of size 2 with 90mm stem inserted. 8mm insert after cementing. Knee is reduced & found to be stable. Lateral retinaculum release done for patella tracking. Wound wash given, wound closed in layer dressing done. Procedure was uneventful

Post op X-Ray:

Intensive care Unit

  • Observation and vital monitoring
  • Mild oozing on the surgical site
  • Patient was obeying commends
  • Patient management done with IV antibiotics, antiemetics, analgesic, DVT Prophylaxis.
  • Dressing done and wound is cleaned
  • Discharge in stable condition.

Post-op Nursing Interventions

  • Observe dressing for bleeding/drainage
  • Ice as ordered
  • Pain medications as ordered
  • Active flexion of foot q1h while awake
  • Continuous passive motion (CPM) device
  • Early ambulation with knee immobilizer
  • Physical therapy as ordered

Position in bed

  • A towel roll should be placed at the ankle to promote knee extension when patients are supine in bed
  • Nothing should be placed behind the operative knee, to promote maximal knee extension and prevent knee flexion contracture.

Post Operative Rehabilitation

  • Rapid post-operative mobilization
  • Range of motion exercises started
  • CPM (0-300)
  • Passive extension by placing pillow under foot
  • Flexion- by dangling the legs over the side of bed
  • Muscle strengthening exercises
  • Full Weight bearing is allowed on first post op day

Phase (Weeks 1-6)

  • Improve knee ROM (aim for at least 900 flexion, increase muscle strength and stability, strengthening: straight leg raises, Quadriceps strengthening with light resistance.

Phase (Weeks 6-12)

  • Improve strength, (ROM-1200 or more), and functional activities.
  • Transition to normal walking without assistive devices.
  • Advanced strengthening: Resistance bands for quadriceos, hamstrings, calf raises
  • Weight –Bearing activities: Partial squats, step-ups
  • Cycling, walking longer distances

Phase (12 Weeks)

  • Continue improving knee functions and overall strength
  • Maintain ROM and prevent weight gain
  • Encouragement to continue exercises independently at home to maintain functional gains.

Conclusion:

Knee Replacement surgery has evolved over the years, offering several options depending on the patient’s condition. Whether it is a total, partial or revision knee replacement, the goal is to relieve pain, improve joint function, and improve quality of life. Recent advances in mechanical and surgical approaches have dramatically improved the surgical outcomes.

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