David R. Lionberger, MD

Physical Therapy

Instructions for the Physical Therapist to Maximize Minimally-Invasive TKR Performance

Informal therapy for patients in the hospital usually begins within 4-6 hours following surgery by the nursing staff and therapist. Patients stand and usually walk WBAT on the day of surgery. On the following day, patients will be seen twice a day for a 30 to 40 minute exercise program where discharge goals of 100 feet and 90° range of motion with independent transfers would have been achieved before they are discharged (usually noon or 13:00.)

It is crucial that patients not miss a physical therapy session after hospital discharge. Even patients who exercise on a daily basis will be expected to be seen and evaluated in the first week after discharge day without fail. If they miss a physical therapy visit, much of the momentum from the recovery after MIS surgery is lost. The first visit must be either Thursday or Friday of the week of surgery. If your therapy department cannot meet this demand or do not complete the preconditioning program with you, we still need a strenuous workout on Friday. Patients should only go to the facility that is capable of providing therapy in this crucial window.

Therapy is done on an every other day basis for 5 weeks with a total of 12 visits. At the conclusion of 5 weeks, their therapy is expected to be complete. In our review of 2009 patients, 60% completed therapy goals by 3 weeks. Please do not require or encourage them to waste time once goals are met.

The expected goals for the first week are 10°-90° of range of motion. If one can reach this point, then they merely work on strengthening exercises and endurance exercises. At the conclusion of the second week, the range should be at 100° or better and within 7° of complete extension. At the conclusion of the third week, range of motion should be 5°-110° and by the fourth week should be 3°-115° Patients achieving 120° before the 5 weeks may undergo a weekly visit for follow-up and guidance with gait training. If patients exceed goals and there is no excessive swelling, they can increase range accordingly. Once 3° to 120° is reached and maintained for 2 sessions they can be discharges with a maintenance program for home.

It's important to realize that the exercise program that is done under the MIS protocol is an abbreviated program that is identical to a typical total knee replacement program. The only difference is that it is completed in 5 weeks or less instead of 8-12 weeks.

If the recovery lags, modalities may be instituted to assist in catching up. Ice therapy can sometimes be helpful, and also extension splints at night in the form of knee sandbag weights can be helpful. Another thing to watch for is swelling because of the small incision. Since there isn't a large incision for drainage to occur from, patients are encouraged to keep their knees elevated more than the traditional midline total knee replacement incision. This is absolutely mandatory in the first 2 weeks. Other than this, there isn’t any special management required for these patients and the rapid rehab has been not only a success in minimizing downtime to the patient, but becomes contagious to other patients who are motivated to pursue such recovery. It has been a treat to be involved in the development of this program, and I continue to work with the industry and therapists who are interested in pursuing these goals to better our capabilities in this rapid rehab program.

If you or your staff notice any of our patients falling behind without improvement using the above measures, please refer them back to me. It is much easier to make midcourse corrections earlier rather than later.

Thank you for your help!

David R. Lionberger, M.D.

--Revised 2010