Wellness & Lifestyles Australia

TOTAL KNEE REPLACEMENT (TKR) &

UNICOMPARTMENTAL KNEE
REPLACEMENT (UKR) E-BOOK
prepared by
Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents

Page No.

IMPORTANT NOTICE ................................................................................................................. 1

INTRODUCTION ...................................................................................................................... 2
KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY.......................................................... 3
Anatomy .................................................................................................................... 3
Degeneration ............................................................................................................... 3
Indications for surgery.................................................................................................... 3
PREOPERATIVE ADVICE AND PLANNING .......................................................................................... 4
Before the surgery ........................................................................................................ 4
After the surgery .......................................................................................................... 4
OPERATION PROCEDURE............................................................................................................ 5
Total knee replacement .................................................................................................. 5
Unicompartmental knee replacement ................................................................................. 5
ACUTE INPATIENT PHASE (WEEK 1) ............................................................................................... 6
Goals......................................................................................................................... 6
What to do.................................................................................................................. 6
What youll notice......................................................................................................... 6
Exercises .................................................................................................................... 7
OUTPATIENT PHASE (UP TO 3-4 MONTHS) ..................................................................................... 11
Hydrotherapy..............................................................................................................13
Stationary bike riding ....................................................................................................17
Exercises on land .........................................................................................................17
SUMMARY ........................................................................................................................... 23
CONTACT US ....................................................................................................................... 24

MANUAL LAST MODIFIED 2/8/2010

IMPORTANT NOTICE
The information provided in this document can only assist you in the most general way. This document
does not replace any statutory requirements under relevant State and Territory legislation.
Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the
material contained in this document, which is provided on the basis that the Office of W&L is not thereby
engaged in rendering professional advice. Before relying on the material, users should carefully make
their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and
should obtain any appropriate professional advice relevant to their particular circumstances.
To the extent that the material in this document includes views or recommendations of third parties, such
views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its
commitment to a particular course of action.
Copyright Australia 2009
This work is copyright. You may download, display, print and reproduce this material in unaltered form
only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart
from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION
Welcome to the W&L series of eBooks. You have chosen the edition on total knee replacement (TKR) and
unicompartmental knee replacement (UKR) rehabilitation.
This resource will be beneficial to anyone who:
Anyone who is interested in the anatomy and biomechanics of the knee joint
Anyone who has knee degeneration problems and is wondering what surgery involves
Anyone who is going to have a TKR or UKR and wants to be able to prepare themselves and know what
to expect in advance
Anyone who is participating in a TKR or UKR rehabilitation program and wants a comprehensive guide
to their exercises
Anyone who is providing a rehabilitation program and wants up to date information with all the
important details
This eBook will cover information about the anatomy of the knee, provide an explanation about the
degenerative process of the knee joint and discuss the alternatives to surgery as well as explaining when it
is best to choose surgery. It also will accompany you from the weeks leading up to surgery until you return
to your normal routine with advice, answers and exercises.
The information provided is up to date and follows industry standard. W&L recommend that you continue
to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to
your specific requirements.

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KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY

Diagram taken from:

VeriMed Healthcare Network (2005), Knee Arthrosscopy Series, Discovery Health, Accessed 1st August 2010
http://healthguide.howstuffworks.com/knee-arthroscopy-series-picture.htm

Anatomy
The knee joint has two parts, the patellofemoral and the tibiofemoral joints. The patellofemoral joint is
between the knee cap (patella) and the femur bone. The femur has a groove at the front which the
patella sits in and is able to slide up and down when the knee bends and straightens. The tibiofemoral
joint is the main one, between the femur and tibia. The joint surface of the tibia (the shin bone) is
relatively flat and has articular cartilage and menisci covering the bone. The femur (thigh bone) is
rounded to allow for a rolling movement on the flat tibia and also has articular cartilage. There are large
muscles and ligaments surrounding the knee joint to keep the joint secure and transmit weight through
the tibiofemoral evenly.

Degeneration
Through muscle imbalances in strength or length, trauma, rheumatoid arthritis or general wear and tear
the joint surfaces can degenerate away. There are many reasons which can cause joint surfaces to wear
away but the general process involves the bone joint surfaces being exposed and rubbing together which
can be painful. Sometimes the inner (medial) or outer (lateral) compartment of the knee wears before the
other so there is arthritis in only one sided.

Indications for surgery

The main reason for surgery is if the there is a large degree of degeneration in the knee joint which cant
be successfully managed with other treatments such as physiotherapy, medications, weight modification
or activity modification.
A total knee replacement (TKR) or unicompartmental knee replacement (UKR) will help
Reduce pain
Increase stability and mobility
Improve the knees functional abilities
Correct alignment or any deformities.
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PREOPERATIVE ADVICE AND PLANNING

Before the surgery

Check with your doctor which medications you should be taking in the lead up to your surgery,
there may be some ones you take regularly which you have to stop or some antibiotics you will
need to start taking before you have the TKR or UKR.
You may wish to donate some of your own blood for the operation although there is the option to
use blood donated for transfusions.
Once you admitted into hospital you will most likely have to go through a screening examination
including x-rays, blood tests, cardiograms and a physical examination.
You will have to fast at least 12 hours before your surgery.
During your last shower before the operation, you will have to use a special soap to wash yourself
and give special attention to your knee which is going to have the replacement.
There is a choice available for anaesthetic, some will make you unconscious during surgery while
others can be used to numb only your lower half. You will have an opportunity to discuss these
options with your anaesthetist and surgeon.

After the surgery

You will notice that your knee retains some warmth and swelling for some weeks after your
surgery.
The early stages of rehabilitation will be crucial for regaining movement in your knee before it
fully heals.
Your exercises which cause discomfort arent at risk of damaging your knee and are important for
gaining function in the long term.
You will need some assistance with walking at first (usually using a walking frame or walking stick
as you improve) but will usually be able to walk independently by 6 weeks after surgery.
With driving, if you have a TKR or UKR on your left knee and drive an automatic you should be
able to recommence driving immediately. Otherwise, it usually takes about 4 weeks before you
will be comfortable enough to drive.
Sexual activity is also appropriate when comfortable.

In order to protect yourself and your knee after surgery it is best to avoid

Activities with quick movements which may stress your knee through twisting, impacting, kneeling
or stop-starting.
Putting a lot of weight through your knee while it is bent (like walking up a steep incline or stairs).
Carrying heavy objects or gaining weight.
Having to bend down to low chairs or toilets

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OPERATION PROCEDURE

Total knee replacement

The procedure takes approximately 2 hours. An incision is made at the front of the knee and quadriceps
muscle detached from the patella so that it can be moved aside and the tibiofemoral joint is exposed. The
joint surfaces of both the femur and tibia are removed to allow for the prosthetic parts to be inserted.
The following components are used in a TKR to replace joint surfaces:

A metal femoral component is either cemented or impacted into the end of the femur to replace
its joint surface.
A metal tibial component has a stem which anchors down into the top of the tibia bone and
replaces the weigh bearing surface of the tibia.
A plastic cover is used to cover the tibia components joint surface to help absorb force, similar to
articular cartilage, and allow the femur and tibia to move smoothly on each other.
In some cases a plastic button is placed over the back of the patella if it has a high level of
degeneration to help it move smoothly over the front of the femur.

Diagram taken from:

(2009), Jumpers Knee Patellar Tendinopathy, Health 2 Sport, Accessed 1st August 2010
http://www.health2sport.com/category/sports/knee-injury-sports/

Unicompartmental knee replacement

This surgery follows a similar procedure to a TKR but only the patellofemoral joint or the inner or outer
part of the tibiofemoral joint is replaced. Usually this surgery means having a smaller incision and quicker
recovery due to the smaller degree of trauma experienced by the tissues surrounding the knee.

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ACUTE INPATIENT PHASE (WEEK 1)

After your surgery you will be given instructions about exercises for rehabilitation. This procedure usually
gives excellent improvements in functional ability such as using stairs, driving and all other activities of
daily living. This outcome relies on improvements made in the early stages of rehabilitation and diligence
with exercises.

Goals
The main goals for this first week are to be able to:

Fully straighten your knee and bend it past 90 (with the help of your hands)
Be able to use your quadriceps muscle to control your knee (see quadriceps control exercise)
Walk normally with the help of a walking stick or walking frame
Be able to do your exercises on your own

What to do

Elevate your operated leg with a pillow under your calf to reduce the accumulation of swelling in your
knee.
Ice the knee and paddle your feet to help swelling to resolve.
Massage your thigh, calf, the sides and back of your knee with moisturising cream.
Your leg may be put on a continuous passive movement (CPM) machine which will bend and straighten
your leg for you but try and contribute to the movement yourself. This may be done for 2-3 hours a
day.

What youll notice

Youll be monitored regularly for blood pressure, heart rate and temperature as well as movement
and sensation in your operated leg.
There will be at least one drain situated in your knee which will be taken out 1-2 days after surgery.
You will continue to have fluids delivered through your veins as well as other medications for a couple
of days.
Youll be given tubigrip (like a bandage) in place of your dressing with T.E.D. (Thrombo Embolic
Deterrent) stockings which are used to stop blood clots forming in your leg while you arent using it as
much. Keep these on for the six weeks (remove only for washing) or as otherwise instructed.
Youll get out of bed the first day after surgery with assistance from hospital staff and will try walking
on the second, usually with a wheelie frame but then progressing to crutches or walking stick.
You will feel tired and walking will be challenging so it is more important to conserve your energy for
completing your exercises.
Youll be in hospital for usually 3 7 days.
It will take 3 4 months for a full recovery so form your expectations with this in mind.

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Exercises
These can be started straight after the operation in bed.
Ankle pumping: Do 10 every hour.

Repeat the following exercise session twice a day:

Quadriceps control: Contract the quadriceps muscle on the top of your thigh to push the back of your
knee into the bed. Hold for 5 seconds and repeat 5 times.

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Knee flexion: Use your hands to help slide your heel towards your bottom until you start to feel an
increase in pain. Stop and hold this position for 20 seconds and repeat 10 times.

Knee straightening in bed: Rest your ankle on top of a rolled up towel or some other support and relax
your knee so that it straightens out fully, hold for 2-3 minutes. Note: It is very important to regain your
ability to straighten your knee early on in the rehabilitation. At first, this exercise may cause pain but it
wont cause any damage to your knee.

Inner range quads exercise: Using a rolled up towel under your knee, contract your quadriceps muscle to
lift your foot off the bed. Ensure that your leg is straight and you are pushing the back of your knee into
the rolled up towel. Gently lower again and repeat 10 times.

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Straight leg raise: With the rolled towel under your foot, contract your quadriceps muscle to lock the
knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds.
Gently lower again and repeat 10 times.

Knee bending on chair: While sitting on a chair try to bend your knee as much as possible, using your
other foot to help push it under and hold for 20 seconds. Relax your leg and repeat 10 times.

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Knee straightening over chairs: While sitting on a chair, rest your ankles on another chair. Place a book
over your knee to help straighten it and relax, holding your knee out straight for as long as possible. Aim
to build up to 10 minutes at a time. Once again, this exercise will hurt but is very important for a full
recovery and wont damage your knee. Use a distraction like TV or have a conversation to make this
exercise easier.

Calf stretch in bed: Sit with your leg outstretched and a band (a belt or towel would be fine) around your
foot. Straighten your knee and pull your foot towards you until you feel a stretch and hold for 20 seconds.

Walking:

Hold the walking stick in the opposite hand to your operated side.
When you plant your operated leg, focus on contracting your quadriceps and buttock muscles to keep
your knee straight.
Focus on bending your knee when your leg swings backwards.
Aim to do short walks frequently at first. When you return home, the incidental walks you do around
the house should be sufficient and longer walks arent required.

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OUTPATIENT PHASE (UP TO 3-4 MONTHS)

This part of rehabilitation is expected to continue for up to 4 months as the knee is still healing and
adjusting. For this reason, it is very important to keep working on your exercises and aim to straighten
your knee because as time goes on it will be harder to make these changes. Continue to see your
physiotherapist, especially if you develop new pains as they will be able to help treat your symptoms.
At this stage it is important to keep up

Massaging tender areas around you knee.

Using ice when your knee becomes hot or has excess swelling, especially after exercise.
Elevating the leg when you rest to help reduce swelling.
Walk in moderation and be sure to rest when you notice excess heat, swelling or aching.

When getting in and out of chairs, try not to rely on hands but focus on contracting your buttock muscles
to lift yourself out of the chair. It will help to shuffle to the front of the chair first and lean forward like
your nose is approaching your knees.

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When managing steps or stairs, it is important to rely on your buttock muscles to perform the movement
and not by pulling yourself with your arms. Early on, the easiest pattern to manage stairs is: good leg first
when going up and operated leg first when going down. As you become stronger and more confident you
can reverse this pattern so that your operated knee becomes more reliable.

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Hydrotherapy
Doing exercises in the water are a great way to strengthen the knee muscles without putting too much
pressure through the joint. As well as strengthening the muscles around the knee, it is important to focus
on technique and control when doing all your exercises so that your brain has practice in controlling your
knee during movements. A hydrotherapy program is started around 2 weeks after the operation. Use this
program as a guide but it is recommended to consult your therapist for specific exercises and intensities.
Warm up:

Walking forwards, sideways and backwards, 2 laps each.

By the edge of the pool to hold on:

Marching on the spot, 20 steps

Bringing your heel to your bottom, 20 times

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Forward and backward pendular swings (floating your leg up in front of you and then swinging it in a
backward direction as far as you can manage) 20 times

Sideward leg swings (lift your leg out to the side trying to keep your trunk still) 20 times

Squats, 10 times (do this exercise on one leg when you gain strength and confidence)

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By the steps:

Step up leading with operated leg and step down leading with non operated leg (this is the opposite to
the stepping order on land), 20 steps

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With a floating cuff:

Attach the floating cuff to your operated foot to assist with these stretches

Quadriceps stretch: stand tall and bend the knee of your operated leg behind you until you feel a
stretch in the front of your thigh. Hold for 30 seconds and repeat twice more.

Hamstring stretch: stand tall and raise your operated leg straight in front of you while keeping your
trunk straight. Feel the stretch at the back of your thigh or in your knee and hold for 30 seconds and
repeat twice more.

Cool down:

Walking forwards, sideways and backwards, 2 laps each.

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Stationary bike riding

Bike riding is a safe way to stretch your knee and increase the amount it is able to bend.

Begin with the seat adjusted up high and no resistance on the wheel.
Try to push the pedals and complete a full cycle, if you can do the full cycle then lower the seat so
that you are unable to complete a cycle.
Push the pedals so that your operated knee is bent and you can feel like it is at the end of its range,
holding the stretch for 20 seconds.
Push the pedals backwards to release the stretch and then repeat 5 times.

Exercises on land
Repeat this program twice a day:
Knee straightening over chairs: Perform this exercise the same as you did in the acute phase. While
sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and
relax, holding your knee out straight for as long as possible.

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Straight leg raise: Perform this exercise the same as you did in the acute phase. With the rolled towel
under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your
whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Standing: While standing focus on holding yourself tall with symmetry. Keep feet parallel, contract your
quadriceps and buttock muscles to control your lower half and raise your chest to make yourself tall. Hold
this posture for 2 minutes, especially after youve been sitting down for a while.

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Calf stretch over step: While holding onto a surface (such as a kitchen bench), have the balls of your feet
on a step or phonebook and your big toes together. Drop your heels down, keep your knees straight and
tuck in your bottom so that you feel a stretch in your calves. Hold this for 30 seconds and repeat 3 times.

Knee flexion: Perform this exercise the same as you did in the acute phase. Use your hands to help slide
your heel towards your bottom until you start to feel an increase in pain. Stop and hold this position for 20
seconds and repeat 10 times.

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Knee bending on the edge of a chair: While sitting on a chair tuck your feet under the chair. Shuffle
forward on the chair until you feel an increase in pain in your knee and hold for 30 seconds. Relax your leg
and repeat 10 times.

Knee bending stepping on a chair: Step your foot onto a chair and lean forward so that you bend your
knee and feel a stretch. Hold for 30 seconds, lean back to release the stretch and repeat 10 times.

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Quadriceps stretch on your tummy: Lying on your tummy have a band hooked around your operated leg
and over the shoulder opposite to your operated side (e.g. left foot and held over your right shoulder) and
pull so that you feel a stretch at the front of your thigh. Hold for 30 seconds and repeat 3 times.

Balancing on one leg: Standing while holding onto supports (for example, chairs either side) shift your
weight over to your operated leg and lift your good leg up. When you feel confident, lift your hands one at
a time and count how long you can hold it. Continue daily until you can hold your balance for more than
20 seconds.

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Weight transfer in lunge: Stand with your operated leg in front and knee slightly bent, put most of your
weight through your operated leg. Check that your hips and shoulders arent twisted or tilted and that
your belly button is directly in line with your big toe. Hold this position for 5 seconds and then step
forward with your good leg. Repeat this step 5 times to form a new walking pattern.

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SUMMARY
In summary, degeneration of the knee joint can occur for many reasons and can be managed through
activity modification, physiotherapy and medications. However, for cases where other interventions
havent been successful, TKR or UKR are available to treat symptoms and have excellent results.
Early rehabilitation will be important for gaining full function back in the knee. Even if there is some pain
with exercise this is not dangerous for your new joint. The more you push yourself in your rehabilitation
the better your long term functioning will be. A full recovery is expected in 3 4 months after surgery
where you can expect to resume your normal activities with less pain, stiffness and general restriction
from your knee.
Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist.
All the best for a speedy recovery,
W&L team.

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CONTACT US
Wellness & Lifestyles Australia
2/59 Fullarton Road, Kent Town SA 5067
P: +61 08 8331 3000
F: +61 08 8331 3002
E: contact@wellnesslifestyles.com.au
W: www.wellnesslifestyles.com.au www.wleducation.com.au
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