Endoprosthesis of the knee joint - TEP of the knee joint

Are you awaiting the replacement of the knee joint? Are you worried what will happen during the surgery, or what kind of rehabilitation awaits you after? You don’t know whether you will be able to do sport with your friends? We have a comprehensible article which will help you to understand, what exactly does complete endoprosthesis involve.

KNEE JOINT

The knee joint is the most difficult joint in the human body. The movement in the joint is a complex combination of movement, rotation and tilting. The joint is burdened during walking several times more than what is the original bodyweight, and it is further increased when walking into stairs, walking up a hill and when carrying something heavy. In the knee joints are meeting two of the longest bones of the human body, from which results again a big pressure in the joint.

More detailed informations about the anatomy can be found in the article: arthrosis of the knee joint.

TEP kolene

WHEN TO START THINKING ABOUT REPLACEMENT OF THE KNEE JOINT?

As it is by every surgery, even replacement of the knee joint is not easy. It is a big interference into the organism and with surgery also come health risks. Therefore think about operation only if you are not able to walk even few steps without a walking stick, pain wakes you up in the middle of the night, when it restricts you, doesn’t enable you to enjoy life, do a sport, visit friends etc.

Doctors on the other hand evaluate the range of deformed changes of the joint and they decide for operation usually when the cartilages are already significantly narrowed, crackled or they are missing completely and on the cartilages of the knee joint are visible bony spurs which restrict the movement of the joint and the pain intensity only grows.

In order for the operation to be successful we recommend you to start with physiotherapy already before the planned operation. Ideal is also manual or mechanical lymphatic drainage, which lowers the painfulness and swelling in the knee and at the same time we recommend you to visit physiotherapeutic sessions, which will help your muscles to get back into condition (it is great to have a perfect muscle strength and elasticity (stretching). Physiotherapist will also focus on preserving the joint range, radial shock wave therapy, which relieves the muscles that are located thanks to the anatomical damage of the joint in an enormous muscle tension and they don’t enable the optimal coordinated activity of the muscles of the leg and pelvis. If your condition was good before the operation, you will very likely successfully go through the surgery and post-operational recovery. But it is important to visit the physiotherapist after the operation.

REPLACEMENT OF THE JOINT

Complete endoprosthesis (TEP) or total joint replacement is composed of 2 parts, that replace the lower part of the thigh bone and upper part of the shin bone, between which is placed polyethylene insert.

One of the goals of operation is securing the joint stability. Especially dynamic stabilizers are responsible for that, muscles of the thigh need to be therefore correctly involved - we talk about muscle coordination, which can be treated by physiotherapist. Conditions for a correct functioning of the joint are recovered physiological axis, which are prerequisite of symmetrical burdening of the leg and it protects against premature release of the implant.

The doctors give most attention to the preservation and recovery of the symmetrical tension of the side ligaments of the body which is always achieved by a precise resection (operative removal) of the bones and partial release of the shortened ligaments. During a symmetrical tension of the side ligaments, the surgeon chooses a responding height of the joint polyethylene insert. The anterior cruciate ligament which is hidden in the joint, is usually damaged by the heavy case of the knee joint arthrosis. Its stability function has to be then overtaken by muscles in the area of the front and back side of the thigh. The posterior cruciate ligament stays preserved, unless its length is shortened because of arthrosis, in such case the doctor has to slightly severe the ligament. Its function can be partly replaced by the shape of the articulatory insert.

The resulting active movement in the operated joint is depending on the strength and elasticity of the muscles of the thigh, especially the quadriceps and flexor muscles of the knee joint. Do not underestimate physiotherapy before operation, the better your physical condition will be before operation, the easier and faster the return to the normal life after the operation will be.

INDICATIONS FOR OPERATION

  • Advanced gonarthrosis not responding to conservative treatment
  • Rheumatoid arthritis
  • Heavy injury
  • Oncological causes
  • Progressive disability of the joints during hemophilia

CONTRAINDICATIONS - WHEN IS OPERATION NOT RECOMMENDED

  • Ischemic disease of the legs (depending on the stage)
  • Condition after infectious inflammation in the knee joint
  • Acute or chronic skin disease of the legs
  • Chronic infection anywhere in the organism

PREOPERATIVE EXAMINATION

Preoperative examination includes thorough internal examination for evaluation of your current health condition and level of operation risks. Part of the preoperative examination is quality X-ray image. It enables the choice of correct type of implant, the estimation of its size and planned of bone resection and centration of the implant. Surgeon will tell you about the process of the operation and what everything it includes and what will the recovery period look like.

DAY OF THE SURGERY

The surgery alone is performed with epidural administration (anesthesiologist will apply the injection into the area of the spine - spinal cord), that means you will be conscious during the operation.

In order to remove the damaged parts of the joint surfaces the surgeon tries to position the implants and movement in the knee with the trial components with corresponding size. In this phase it is important to check the tension in the ligaments and alternatively achieve the symmetric tension with gradual release of the soft structures (muscles, tendons, joint capsule…) in the area of the joint. Experienced surgeons speak about this phase as a basic and determining phase crucial for the result of the operation. Joint replacements will be fixed by bone cement, or by corresponding quality of the bone and used material with a special surface enabling osteointegration (adhesion of the bone mass with the implant) even without bone cement. During a significant disability of the knee joint, the patellas can be replaced as well.

WHAT CAN YOU EXPECT AFTER THE OPERATION

First few days after operation you will get compressive sleeves, which will prevent formation of inflammation in the veins or released thrombosis from the legs, and by simple exercises you will support the blood circulation in the legs. Approximately the second day you will have to meet with physiotherapist and your task will bet to stand up, alternatively you might walk few steps with the help of crutches, you will start by exercising isometric exercises (clenching and releasing) muscles of the legs. We try to achieve and keep a full extension (stretching) of the knee joint and gradually increase the range of movement into flexion (bending), which should be at least 90° before you leave the hospital. Some facilities supplement the active exercising with passive exercising with the so called continuous passive motion machine (CPM), which moves with the operated leg by itself in preset degrees.

Very important is also the care for scar and the soft tissues (tendons, muscles and ligaments), disrupted during the operative treatment. Manual techniques will help, laser or focused shock wave therapy is also ideal, which supports the regeneration of the soft tissues, adhesion of the new vessels into the operated area, that accelerates the regeneration. Radial shock wave therapy on the other hand helps to relieve the muscle tension in the area of the thigh, calf or buttocks, which occurs as a reflexive response to the operative intervention. If the excessive muscle tension gets released, the pain in the knee area will also be released. Physiotherapist then spends the sessions on strengthening your muscles in the thigh area (the so called dynamic stabilisers of the knee), improved proprioception and deep stabilizing system for regaining the old movement stereotypes. With success we use a whole lot of techniques on a neurophysiological basis, such as DNS according to Kolář, sensory motor skills, method according to Roswitha Brunkow, Vojta method, etc..

Very ideal for healing of the wounds and lowered painfulness is the use of kinesio tape. We use it as a supportive treatment against swellings in the joints and simultaneously during mechanical or manual lymphatic drainage.

Optimal range of movement and muscle indication is achieved between third and sixth month after operation. In future you should avoid kneeling, squats and jumping. You will preserve the joint implant that way longer - because after all it also has a limited lifespan.

CASE FROM A CLINICAL EXPERIENCE

A female visited us at FYZIOklinika with painful problems of the knee. She was waiting for operation, she needed a complete endoprosthesis of the knee. The knee was significantly swelling and painful. The pain was shooting into the whole leg and foot. In a certain degree the knee got blocked which was accompanied by a significant pain, and because of the swelling it was less moveable and flexible.

She started to visit FYZIOklinika shortly before the operation, she was treated with shockwave therapy, and she was also treated with mechanical lymphatic drainage 2-3x per week in length of 3 months. At the end of the treatment she felt much better, the knee was without swelling and the painfulness significantly dropped down. She wasn’t troubled anymore by the pain shooting into the whole leg. She didn’t even have to take painkillers. Only sometimes at night she still needed some painkillers, but even after she took them the pain remained in a certain degree. This fact relates degenerative wearing off of the knee joint cartilage, therefore the joint replacement here was still needed.

Therapeutic point of view

It is good to go to lymphatic drainage and physiotherapy before the operation. The mobility of the whole leg will improve, smaller swelling does not restrict the blood vessels, the wound heals more easily and client will be rehabilitated faster, which will enable the client to return faster back to normal life. Lower painfulness contributes to a more positive approach to the treatment, operation and postoperative treatment. Mechanical lymphatic drainage before and after operation lowers the risk of formation of inflammation, thrombosis and embolism.

VIDEO TUTORIAL OF PHYSIOTHERAPEUTIC EXERCISES

PNF for legs

 

EXERCISE INSTRUCTIONS



Author:
Mgr. Iva Bílková, FYZIOklinika fyzioterapie Ltd, Prague, Czech Republic

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