Knee replacement
In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk.
[5] Knee replacement surgery is most commonly performed in people with advanced osteoarthritis and should be considered when conservative treatments have been exhausted.
Pain often is noted when performing physical activities requiring a wide range of motion in the knee joint.
[citation needed] Two angles used for this purpose are: The patient is to perform range-of-motion exercises, and hip, knee and ankle strengthening as directed daily.
As of 2017, there was insufficient quality evidence to support the use of pre-operative physiotherapy in older adults undergoing total knee arthroplasty.
[19] The surgery involves exposure of the front of the knee, with detachment of part of the quadriceps muscle (vastus medialis) from the patella.
[20] Whether the posterior cruciate ligament is removed or preserved depends on the type of implant used, although there appears to be no clear difference in knee function or range of motion favoring either approach.
During the operation any deformities must be corrected, and the ligaments balanced so the knee has a good range of movement, and is stable and aligned.
[citation needed] In recent years, there has been an increase in technology assistance with implantation of total knee replacements.
[26] Local anesthesia infiltration in the pericapsular area using liposomal bupivacaine provides good analgesia in the post-operative period without increasing the risk for instability or nerve injury.
The current body of evidence suggests if a tourniquet is used in knee replacement surgery, it probably increases the risk of severe side effects and postoperative pain.
][31] There are concerns regarding tibial loosening after implantation, prohibiting widespread adoption of cementless knee replacements at this time.
Surgeons who do not routinely resurface the patella do not believe that it is a significant contribution to pain, when there is no evidence of arthritis to the patellofemoral joint.
[citation needed] The posterior cruciate ligament (PCL) is important to the stability of the knee by preventing posterior subluxation of the tibia, reducing shear stress, increasing flexion and lever arm of the extensor mechanism by inducing femoral rollback upon flexion, and thus minimizing polyethylene abrasion through reducing stress applied to the articular surface.
Proponents of retaining the PCL advise that it is difficult to balance a CR knee and unnatural physiologic loads may increase wear of the polyethylene.
There are different definitions of minimally invasive knee surgery, which may include a shorter incision length, retraction of the patella without eversion (rotating out), and specialized instruments.
A minority of people with osteoarthritis have wear primarily in one compartment, usually the medial, and may be candidates for unicompartmental knee replacement.
Advancements in implant design have greatly reduced these issues but the potential for such an event is still present over the life span of the knee replacement.
"[3] Some medications used to thin the blood to prevent thrombotic events include direct oral anticoagulants (i.e. rivaroxaban, dabigatran, and apixaban), low-molecular weight heparins (i.e. dalteparin, enoxaparin), and the antiplatelet agent aspirin.
A detailed clinical history and physical examination remain the most reliable tool to recognize a potential periprosthetic infection.
In some cases the classic signs of fever, chills, painful joint, and a draining sinus may be present, and diagnostic studies are simply done to confirm the diagnosis.
A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint; or Four of the following six criteria exist: 1.Elevated serum erythrocyte sedimentation rate (ESR>30mm/hr) and serum C-reactive protein (CRP>10 mg/L) concentration, 2.Elevated synovial leukocyte count, 3.Elevated synovial neutrophil percentage (PMN%), 4.Presence of purulence in the affected joint, 5.Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or 6.
[67] To increase the likelihood of a good outcome after surgery, multiple weeks of physical therapy are needed to help the patient return to normal activities, as well as prevent blood clots, improve circulation, increase range of motion, and eventually strengthen the surrounding muscles through specific exercises.
[68] In most medical-surgical hospital units that perform knee replacements, ambulation is a key aspect of nursing care that is promoted to patients.
[69] Promotion and execution of early ambulation on patients reduce the complications, as well as decrease length of stay and costs associated with further hospitalization.
[70][71] There is no evidence that CPM therapy leads to a clinically significant improvement in range of motion, pain, knee function, or quality of life.
[70] Sling therapy is a therapeutic modality used postoperative in order to decrease stiffness and improve range of motion following the procedure.
In sling therapy, the patient's leg is placed in a standard tubular bandage that is suspended from a cross brace fixed to the bed while lying on their back.
Unlike CPM, the use of sling therapy allows the patient to perform active knee flexion and extension with their leg suspended, minimizing gravity's resistance.
By actively mobilizing the joint using their own muscular strength instead of outside forces like in CPM, studies show that there are clinically relevant benefits.
