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December 2009
New Knee for Old
Dr Chandramouli
Got a new knee? Like your old one better? Well if you've answered yes to both those questions then here is what you do: bring out an imaginary mop. And mop out all thoughts related to self-pity and laziness.

Your new knee is not the cause for your problems - it's your second chance. So treat this one the way you should and soon you'll forget it's even here. Total Knee Replacement (TKR) is a major surgical procedure. With awareness and acceptance of the procedure, the numbers of TKR surgery has increased phenomenally in the world and also in our country. If you have recently undergone a knee replacement surgery and are suffering while doing normal day-to-day activities, then you're doing something wrong. There is only a certain amount of what a doctor can do for you. The patient must be equally strong willed to help himself or herself. Here is a list of 10 protocol measures you must take to ensure a quick and healthy recovery.

Pre-operative Counseling
This is the most important step for the patient's recovery. This awareness of the patient can mentally prepare him/ her to undergo TKR with understood expectations. In this treatment, more than the do's, the don'ts list should be well understood by the patient, such as squatting and kneeling activities should not be done. Understanding this, the patient can be prepared post-operatively in relation to their day-to-day living and also with their occupations.

Timing of Surgery
This is to have an optimum expected result as predicted during the preoperative period.

Pain Management
This is one of the major factors leading to good recovery. Post-operatively, epidural anesthesia can be used as analgesic to get good pain relief, which will help in cooperating for physiotherapy. Epidural analgesia can be used upto 3rd or 5th post operative day. The acute pain of surgical procedure reduces by 1st to 2nd postoperative day. Following which, oral analgesics can be used to get pain relief and also to augment physiotherapy.

Physiotherapy for a patient has two effects. One is to improve the muscle strength of the thigh and calf muscles, and the other is to get mobility. For the first 3 to 4 weeks, the patient must exercise without weights to improve muscle strength. Later on, one can move onto light weights. The most important muscles are gluteal muscles, quadriceps, hamstring and calf muscles.

The first exercise to be started during the immediate post-operative period is the Ankle Pumping Exercise. This is done to prevent D.V.T (Deep Vein Thrombosis) in the lower limb. At the same time, Deep Breathing Exercises are to be done to prevent Orthostatic pneumonia etc. As your condition progresses you can start quadriceps exercises, straight leg raising exercises, pelvic bridging exercises and gradually increase it's frequency and duration over a period of 2 to 3 days. By first or second post-operative period, the patient can be mobilized with the help of walker. This will instill lot of confidence giving the patient a rush of enthusiasm to perform better physiotherapy.

Occupational Therapy
Occupational Therapy is done to get the patients back to their normal day-today routines at the earliest. By the first week, the patient is trained to walk with the help of a walker from room to room and use of staircases few steps at a time. By the 3rd to 6th week, depending on the patient's capacity to perform and also the strength gained, he/she is shifted from the walker to a walking stick for another 2 to 3 months. This helps in giving the patient confidence to walk further distance and at the same time prevents any chances of stumbling. By 3rd month the patient can be left to walk freely.

Regular Follow-up
It is important to regularly follow up with the surgeon or the knee replacement clinic to ensure the patient has a healthy recovery. Regular and emergency care can be given if needed. Also, if you find that you are going through any discomfort, do not hesitate to call your doctor. As delaying the problem can make it worse.

Management of Root Cause
Understand what caused your knee problem in the first place. And avoid situations where it might reoccur.

Management of Associated Medical Conditions
Associated medical conditions should also be kept under check. For example if you are suffering from diabetes, consumption of sugar should be kept under check for good physiotherapy program. Controlled hypertension leads to good physiotherapy tolerance. So also with hypothyroidism, reduction in body weight and trying to maintain a straight front prevents wearing of the joint.

Adequate Insurance Coverage
Knowing that total knee replacement is a major surgery incurring high expenditure, one should bear adequate insurance coverage for the procedure, so that the procedure is not rejected by the patient, due to financial constraints.

Living Life with Expected Limitations
Living life with expected limitations is very important i.e. capacity matching performance and also including don'ts in life by lifestyle modifications. Have a healthy knee in the year ahead!
Dr.Chandramouli is Consultant - Orthopaedic Surgeon at Apollo Hospitals, Bangalore

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