LC 1 DHY Slide PDF

LONG CASE
Mobilization Disturbance ec Post Total

Knee Arthroplasty Dextra + Osteoarthritis
Genu Sinistra Grade III + Obesity Grade II
PPDS : dr. Advendila Margaretha Artz
SPV : dr. Mathilda Albertina, Sp. K.F.R
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TINJAUAN PUSTAKA
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Osteoartritis (OA)
Gangguan progresif non-inflamasi non-erosif pada sendi yang
menyebabkan kerusakan tulang rawan artikular dan
pembentukan tulang baru atau osteofit pada permukaan dan
tepi sendi.
Osteoartritis merupakan penyebab utama morbiditas dan

kecacatan kronis.
Prevalensi osteoartritis pada perempuan Indonesia mencapai 8,5% dan laki-laki

6,1% menurut data tahun 2018. Wanita memiliki prevalensi lebih besar
dibandingkan pria.
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➢ Etiologi OA :
▪ Primer (idiopatik)
▪ sekunder.
➢ Penyebab dan perkembangan OA lutut ➔ perubahan dramatis dalam

metabolisme tulang rawan → degenerasi tulang rawan artikular dan tulang,
(terkait peradangan).
➢ Fungsi tulang rawan :

▪ Lubrikasi Sendi
▪ Menyediakan permukaan yang lebih halus pada kartilago artikular sehingga
artikulasi gesekan menjadi lebih rendah.
▪ shock absorber.
▪ Meminimalkan tekanan tinggi pada tulang subkondral.
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KETIDAKSEIMBANGAN ANTARA SINTESIS DAN
DEGRADASI ECM
Kondrosit
Mengatur dan
memelihara komponen
ECM (Kolagen dan PG)
Kondrosit
Kondrosit APOPTOSIS
Produksi dan degradatif
matriks melalui enzim
degradatif dan enzim Few Years Later
sintesis. Enzim degradatif Enzim sintesis
Recruitment Dibersihkan oleh

Joint Matrix Kelemahan Matrix
Makrofag → sel tipe A terkelupas
yang berada pada Mice Kartilago
INFLAMASI membrane sinovial
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CEDERA TULANG RAWAN
Berbagai jenis dan kedalaman

kecacatan pada tulang rawan:
1. Cedera tipe 1 (dangkal)
2. Cedera tipe 2 (ketebalan parsial)
3. Cedera tipe 3 (full-thickness)
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DIAGNOSIS
Kriteria •Klinis
klasifikasi •Klinis/ laboratorium
ACR 2012 •Klinis/ radiologi
KRITERIA KLINIS
(nyeri lutut + 3 dari 6 poin)

• Usia > 50 tahun
• Kaku pada pagi hari < 30 menit
• Krepitasi saat lutut bergerak
• Nyeri tekan pada lutut
• Pembesaran tulang
• Tidak teraba adanya panas pada lutut
ACR Clinical classification criteria for Osteoarthritis of the knee. American College of Rheumatology. 2012.
KRITERIA KLINIS/LABORATORIUM
• Usia > 50 tahun • Tidak teraba adanya panas

• Kaku pada pagi hari < 30 pada lutut
menit • Laju endap darah (LED)
• Krepitasi saat lutut <40mm/jam
bergerak • Rheumatoid factor < 1:40
• Nyeri tekan pada lutut • Cairan sinovium
• Pembesaran tulang menandakan adanya OA
KRITERIA KLINIS/RADIOLOGI

+ osteofit pada X-Ray lutut
• Usia > 50 tahun
• Kaku pada pagi hari < 30 menit
• Krepitasi saat lutut bergerak
KLASIFIKASI KELLGREN DAN LAWRENCE
❖ Grade 1 (diragukan): diragukan penyempitan ruang sendi dan kemungkinan adanya osteofit
❖ Grade 2 (minimal): terdapat osteofit yang pasti dan kemungkinan penyempitan ruang sendi
❖ Derajat 3 (sedang): terdapat osteofit multipel sedang, penyempitan ruang sendi yang pasti dan beberapa sklerosis dan
kemungkinan kelainan bentuk ujung tulang
❖ Grade 4 (parah): terdapat osteofit besar, penyempitan ruang sendi yang nyata, sklerosis parah dan kelainan bentuk ujung
tulang yang pasti.
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MANAJEMEN MULTIMODAL UNTUK OA
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TOTAL KNEE ARTHROPLASTY (TKA)
Indikasi utama TKA :
• Menghilangkan rasa sakit yang disebabkan oleh • Kontraindikasi absolut :
radang sendi parah, dengan atau tanpa • Sepsis lutut yang baru terjadi
deformitas yang signifikan • Diskontinuitas mekanisme ekstensor atau
• Pada pasien yang lebih muda : disfungsi berat
• Adanya gangguan fungsional yang signifikan dari • Deformitas recurvatum sekunder akibat
osteoarthritis,
• Artritis dengan tingkat nyeri yang bervariasi kelemahan neuromuskular
disertai dengan deformitas.
• Kontraindikasi relatif:
• Penyakit aterosklerotik yang signifikan pada kaki
operasi
• Kondisi kulit seperti psoriasis dalam bidang operasi
Sebelum operasi dipertimbangkan, tindakan • Penyakit stasis vena dengan selulitis berulang
perawatan konservatif harus dilakukan, termasuk • Artropati neuropatik
terapi fisik, obat antiinflamasi, suntikan intraartikular, • Super-obesitas (BMI≥50)
modifikasi aktivitas, dan penggunaan alat bantu • Infeksi saluran kemih berulang
untuk ambulasi. • Riwayat osteomielitis di dekat lutut
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Surgical Approach untuk TKA Primer
•Measured resection
• Bergantung pada 3 penanda femoral:
• PCA
• Transepicondylar axis (TEA)
• Sumbu AP lutut juga dikenal sebagai garis whiteside.
• Gap balancing
• Tujuan dari gap balancing adalah untuk
mengoptimalkan simetri celah fleksi dan ekstensi.
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Fiksasi Prostesis TKA
Fiksasi prostesis TKA

• cemented
• cementless
• hybrid
➢ Tingkat keberhasilan metode fiksasi cementless dilaporkan sebanyak 72% dan 94%
dengan metode fiksasi cemented pada pasien 10 tahun pascaoperasi TKA.
Gold standard teknik fiksasi ➔ Cemented
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Rehabilitasi pada Total
Knee Arthroplasty
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CASE PRESENTATION

IDENTITY
▪ Name : Mrs. S
▪ Date of Birth : 30/12/1961
▪ Age : 61 years old
▪ Gender : Female
▪ Marital Status : Married
▪ Education : Medical degree
▪ Occupation : Doctor
▪ Refferal Doctor : Dr. dr. Muhammad Sakti,Sp.OT (K)
▪ Refferal Diagnosis : Post Total Knee Arthroplasty Dextra +
Osteoarthritis Genu Sinistra Grade III
▪ Date of Referral : October 28th 2022
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ANAMNESIS
•Chief Complaint: Pain at the right knee after Total Knee Arthroplasty
• Operated day on October 13th 2022 at Wahidin Hospital.
• The pain is felt in the area of the right knee like a sharp pain, does not radiate, not felt
continuously and mainly felt when she walking or when the knee and leg are moved
with NRS 6/10 and was felt less than 5 minutes.
• Pain decreased at rest with NRS 2/10.
• The patient felt the legs still swollen.
• The patient also complained of pain in her left knee which felt intermittent but at this
time the pain was not felt so much.
• The condition of the left knee is not really hurt either during activity or not with NRS
2/10.
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HISTORY TAKING
History before the surgery:
• The patient began to feel pain in the right knee. She got the Xray of her knee and diagnosed
In the early 2016 Knee Osteoarthritis Dextra grade III. But the patient did not seek any treatment because the
pain was still bearable so the patient only applied voltaren on her right knee if it hurt.
• The pain in the right knee is getting worse. The patient went to the Anesthesiology department
End of 2016 on Awal Bros Hospital to got the pain management.
• Pain in the right knee was still felt, the patient came to the orthopedic department at Awal
In 2018 Bros Hospital to receive therapy. The patient was given 3 injections of hyaluronic acid for 3
months.
• The patient went to remote areas during Covid 19, and because she walked a lot, the patient
In 2020 felt pain in her right knee that was getting worse.
August 2022 • The patient felt the pain on her right knee was unbearable until it was difficult to walk.
• She came to the Orthopaedic department and got Xray of her left and right knee. She was
October 6th 2022 diagnose Knee Osteoarthritis dextra grade IV and Knee Osteoarthritis sinistra grade II. The
patient was planned for surgery and referred to Wahidin Hospital.
October 13th 2022 • The patient was operated of Total Knee Arthroplasty dextra at Wahidin Hospital.
October 28th 2022 • The patient referred to PM&R Department for rehabilitation.
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HISTORY TAKING
➢ History of past illness:
o Hypertension (-), diabetes mellitus (-), cardiopulmonary problems (-).
➢ History of family illness:

o There is no family history of osteoarthritis, hypertension, diabetes mellitus
➢ History of Medication:
The patient is taking postoperative medication from orthopedics:

▪ Natrium diklofenak 50 mg 2x1 (if patient felt pain)
▪ Levofloxacin 1x 500 mg for 2 weeks
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HISTORY TAKING
• History of Functional and Vocational Activity
o Vocational:
▪ She is a pensionary doctor in Puskesmas Antang. Now the patient work at Salsabila and
Fauziah Clinic in Antang. She works approximately for 4-6 hours/ day. Mostly she sitting
while working.
o Marital Status: Married, with 2 children.
o Living situation:
▪ She leaves with her husband and daughters, in one floor house.
▪ Her bedroom is near the toilet.
▪ They used sitting toilet.
o Habits: The patient has no history of smoking or consuming alcohol.
o Hobby: The patient's hobby is cooking.
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HISTORY TAKING
• Psycho-Socio-Economic Status
o Educational: The patient graduated from a medical degree and is currently working as a doctor
in Fauziah Clinic and Salsabila Clinic. Patients get civil servant pension benefits for extra
income.
o House Condition & House plan:
• Patient has 1 floor house consist of: 1 garage, 1 living room, 1 dining room & kitchen, 1 bathroom
using sitting toilet, and 3 bedrooms.
o Psychiatry history: The patient has no history of psychiatric illness (depression, anxiety,
suicidal or other psychological problem).
o Habits: The patient has no history of smoking or consuming alcohol.
o Community living: The patient still likes to get socialized with her neighbor.
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TIME DAILY ACTIVITY (before surgery) METS
05.00 – 05.15 Wake up 1,3
05.15 – 05.45 Sholat 2
05.45 – 06.15 Reading Al-Qur'an with voice 1,5
06.15 – 06.45 Watching TV in sitting position 1
06.45 – 07.30 Sweeping house and cleaning cabin 3
07.30 – 08.00 Bathing 2 Total energy expenditure (TEE):
08.00 – 08.30 Preparing meals for family breakfast 2
08.30 – 09.00 Breakfast 1,5 Body Weight (kg) x METs in 24 hours = 3.634,4
09.00 – 09.30 Washing dishes, helped with assistance 2
09.30 – 10.00 Prepare and leave to work 2
10.00 – 12.15 Working (sitting, talking involved, and meeting) 3 Basal Metabolic rate (BMR) Harris Benedict
12.15 – 12.45 Sholat at clinic 2 Formula:
12.45 – 13.15 Lunch at clinic 1,5
13.15 – 14.45 Working (sitting, talking involved, and meeting) 3 = 66,5 + (13,8 x weight in kg) + (5 x height in cm)
Walking, gathering things, ready to leave (going 3 - (6,8 x age in years)
14.45 – 15.15 home) = 66,5 + (13,8 x 77) + (5 x 155) – (6,8 x 61) =
15.15 – 15.45 Sholat at home 2 1,489.3 kCal
15.45 – 16.20 Bathing 1,5
16.20 – 17.30 Sitting in front house + Socialize with neighbour 2,8
17.30 – 18.00 Preparing meals for family dinner 2
Physical activity level:
18.00 – 18.30 Sholat 2
18.30 – 19.00 Dinner 1,8 TEE/BMR = 3.634,4/1.489,3 = 2,440 (Active)
19.00 – 19.30 Sholat 2
19.30 – 21.30 Watching TV in sitting position with family 1,3
21.30 – 05.00 sleeping 1
TOTAL 46,2 27
TIME DAILY ACTIVITY (POST OPERATIVE) METS
05.00 – 05.15 Wake up 1,3
05.15 – 05.45 Sholat in sitting position 1,5
Physical
05.45 Activity
– 06.15 Reading Level
Al-Qur'an with voice 1,5
06.15 – 06.45 Watching TV in sitting position 1
Total energy expenditure (TEE):
06.45 – 07.30 Bathing 2
07.30 – 08.00 Breakfast 1,5 Body Weight (kg) x METs in 24 hours =
Sweepping house in light intensity with 2,5 2.510,2
08.00 – 10.00 assistance
10.00 – 11.00 lying quietly 1,3
11.00 – 12.00 Preparing meals with assistance 2 Basal Metabolic rate (BMR) Harris Benedict
12.00 – 12.15 Sitting in front house 1,3 Formula:
= 66,5 + (13,8 x weight in kg) + (5 x height in
12.45 – 13.15 Lunch 1,5
1
cm) - (6,8 x age in years)
13.15 – 15.15 sleeping
15.15 – 15.45 Sholat in sitting position 1,5 = 66,5 + (13,8 x 77) + (5 x 155) – (6,8 x 61) =
15.45 – 17.00 Watching TV in sitting position 1,3 1,489.3 kCal
17.00 – 17.30 Sitting in front house 1,3
17.30 – 18.00 Bathing 1,5
18.00 – 18.30 Sholat in sitting position 1,5 Physical activity level:
18.30 – 19.00 Dinner 1,8
TEE/BMR = 2.510,2/1.489,3 = 1,685 (Active)
19.30 – 21.30 Watching TV in sitting position with family 1,3
21.30 – 05.00 sleeping 1
TOTAL 34,1
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FIGURE OF THE PATIENT’S HOUSE
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PHYSICAL EXAMINATION
•Taken on October 28th 2022.
• General appearance: Good
• Consciousness: Composmentis (GCS 15)
• Nutritional status
o Body Weight: 77 kg ; Body Height: 155 cm ;
o Body Mass Index: 32 (Obese class 2: 30,0-34,9)
• Vital signs
o Blood Pressure: 130/80 mmHg
o Heart Rate: 86 x/minute
o Respiratory Rate: 20 x/minute
o Temperature: 36.8 oC
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PHYSICAL EXAMINATION
• GENERAL STATUS
o Head and Neck: No anemia, no icterus, no cyanosis.
o Thorax: Simetris, no retraction.
o Lung: Normal vesiculer sound, no wheezing or ronchi.
o Cor: S1-S2 sound reguler, no murmur, no gallop.
o Abdomen: Normal peristaltic sound, liver and spleen unpalpable.
o Extremities: Acral warm, no edema, CRT < 2 second.
▪ Balance
• Sitting static balance adequate
• Standing static balance adequate
• Sitting dynamic balance adequate
• Standing dynamic balance inadequate
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POSTURE
▪ From the anterior view:
• Head is in the midline, left shoulder slightly
elevate, symmetrical body arm distance, no pelvic
obliquity, no genu varus/valgus, no abnormalities in
ankle and foot.
▪ From the lateral view:
• No forward head, spine curvature was difficult to
evaluate (impression normokyphotic thoracal,
normolordotic lumbal), slight anterior pelvic tilt,
slight knee flex, no ankle rotation.
▪ From the posterior view:
• Head is in the midline, left shoulder slightly
elevate, symmetrical body arm distance, no pelvic
obliquity, no genu varus/ valgus, no ankle valgus /
varus.
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BODY FUNCTION
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Sensory Function and Pain
Proprioceptive Genu dextra Genu sinistra
function Joint position Not tested Could sense joint position
Kinaesthesia Not tested Could sense joint movement

Musculoskeletal Source of Data Result
Pain Anamnesis Pain in the right knee due to post op TKA dextra. The pain is felt like a
sharp pain, does not radiate, intermittenly and mainly felt when she
walking or when the knee and leg are moved with NRS 6/10 and was felt
less than 5 minutes. Pain decreased at rest with NRS 2/10. Pain in her left
knee which felt intermittent, NRS 2/10.
Physical Tenderness (+) on operated scar, medial joint line, lateral joint line genu
Examination dextra.
Tenderness (-) genu sinistra.
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Functions of the Respiratory System
Function Items Results
Respiration function Respiration rate 20 x/minute
Respiratory rhythm Normal, rhythmic
Depth of respiration Single Breath Count Test 35

Chest expansion 3,5-3-3,5 cm
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Additional Functions and Sensations of the
Cardiovascular and Respiratory Systems

Cardiorespiratory Oksigen Saturation 99% room air at rest.
Function
Exercise tolerance General physical 6MWT: 280 Meters.
functions endurance (Mets: 12.38 / 3.5 = 3.53)
Aerobic capacity VO2 max = (280 x 0.03) + 3.98 = 12.38
ml/kg/min.
Fatigability Borg Scale:
Before 6MWT: 9 – 0 – 3
After 6MWT:
11 – 0 – 4
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Functions Related to Metabolism and the
Endocrine System

General metabolic Body Mass Index Body weight : 77 kg
functions Body height : 155 cm
BMI : 32 (obese class 2: >30.0)
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Functions of the Joints and Bones
Function Area Result
Mobility of joint functions Lower Extremity Knee Dextra Sinistra
Flexion 10 – 100 (Pain) 0 – 135

Extension 100– 10 (Pain) 135 – 0
Stability of joint functions Knee Joint • Varus stress test -/-
• Valgus stress test -/-
• Lachman’s sign -/-
• Anterior Drawer test: -/-
• Posterior Drawer test: -/-
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Muscle Power Functions
MMT
Muscle group Right Left

Lower Extremities
Hip
Flexion 5 5
Extension 5 5
Adduction 5 5
Abduction 5 5
Internal Rotation 5 5
External Rotation 5 5
Knee
Flexion 4 5
Extension 4 5
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Motor Reflex Functions
Function Items Right Left
Motor reflex function Physiological reflexes KPR Not tested +2
APR +2 +2
Involuntary movement Berg Balance Score Total Score: 33/56 (high risk of fall).
reaction function
The Table listed below.
Gait pattern function Result
• Decreased Velocity, decreased cadance
• 2 point gait with quadripod ; Looking downward
• Minimal Initial Contact (heel strike).
• Slight Body sway to the right
• normal arm swing , normal shoulder, no pelvic obliquity
• Minimal flexion on preswing at the stance phase ,wide base
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Gait Examination
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Berg Balance
Scale
33/56
(high risk of fall)
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Functions of the Skin
Function Items Result
Protective scar wound post operation on anterior
function of Protective functions of the midline of genu dextra: slightly edema
the skin skin (+), redness (+), pus (-), blood (-).
Repair functions of the open wound (-), Crust (+)

skin
Sensations related to the Yes.
skin such as itching,

burning sensation and
tingling.
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Geriatric Giant
Point Result
Isolation No
Instability Yes
Impecunity No
Intellectual impairment No
Impairment of vision No
Impairment of hearing No
Immobility No
Infection No
Immune deficiency No
Inanition No
Insomnia Yes
Impaction No
Incontinency No
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BODY STRUCTURE
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Structure of Lower Extremity
Structure of lower Right Left
extremity
Post total knee arthroplasty Osteoarthritis grade III (Kellgren-
• Look: Lawrence)
Knee Joint
scar wound post operation (+) on anterior • Look:
midline, slightly edema (+), redness (+), pus edema (-), redness(-)
(-), Crust (+) Feel :
• Feel : Warmness (-), tenderness (-)
Warmness (+), tenderness (+) on operated • Move:
scar, medial joint line, lateral joint line.
Crepitation (+), ROM full for flexion and
• Move: extension.
Crepitation (+), limited ROM at knee flexion Special test:
and extension.
o Patellar grinding test: +
• Special test:
o Patellar grinding test: NT Ballotement : (-)
o Ballotement : -
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Structure of Lower Extremity
Structure of lower extremity Right Left
Bones of lower leg ALL: 98 ALL: 98
TLL: 94 TLL: 94
Q-Angle: 8o Q-Angle: 8o
Muscles of lower leg Thigh circumference: 55 Thigh circumference: 58
Calf circumference: 35,5 Calf circumference: 39
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ACTIVITIES AND PARTICIPATION
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Changing and Maintaining Body Position
Activity area Item Result
Changing basic body position Lying down Able
Prone Unable
Squating Unable
Kneeling Unable
Sitting Able
Standing Able
Bending Able
Maintaining a body position Maintaining a lying position Able
Maintaining a prone position Unable
Maintaining a squatting position Unable
Maintaining a kneeling position Unable
Maintaining a sitting position Able
Maintaining a standing position Able
Transferring one self Transferring oneself while sitting Able
Transferring oneself while standing Able
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Carrying, Moving, and Handling Objects
Activity area Result
Lifting and carrying objects Able
Fine hand use Able
Hand and arm use Able
Carrying on shoulders, hip and back Able
Putting down objects Unable to putting down the heavy object
Pushing with lower extremities Unable to pushing with right leg
Kicking Unable to kicking with right leg
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Walking and Moving
Activity area Item Result
Walking Short distances Able
Long distances Unable
On different surfaces Able
Around obstacles Able
Crawling Unable
Climbing Unable
Running Unable
Jumping Unable
Swimming Unable
Moving around in different locations Within the home Able
Within building outside the home Unable
Outside the home and other Unable

buildings
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Moving around using transportation
Using Using private motorized the patient has a private car as a passanger
transportation transportation
Using public motorized Able to use taxi / grab but unable to take
transportation public transportation (bus)
Driving Driving human-powered Unable
transportation
Driving motorized vehicles Unable
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10 Barthel Index
5
5
Score Interpretation
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91-100 Independent
10
61-90 Mild dependency
10
41-60 Moderate Dependency
10
21-40 Severe Dependency

10
10
0-20 Total dependency
0
80
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WOMAC SCORE
44 45,8
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Household Tasks
Activity area Result
Preparing Preparing simple meals Able to organizing, cooking and serving meals with a small number of
ingredients that require easy methods of preparation and serving, such as
Meals making a snack or small meal.
Preparing complex meals Unable to planning, organizing, cooking and serving meals with a large number
of ingredients that require complex methods of preparation and serving,
because the patient is unable to stand for long.
Doing Washing and drying clothes and Unable washing clothes and garments by hand and hanging them out to dry in
garments the air because the patient has difficulty in several positions that are carried
Housework
out to wash clothes using assistive devices.
Cleaning living area Able to cleaning the living areas of the household, such as by tidying and
dusting, sweeping, swabbing, but unable to mopping floors, cleaning windows
and walls, cleaning bathrooms and toilets, cleaning household furnishings.
Community, Social and Civic Life
Participation Items Results
Community life Informal Association Currently patients cannot join the Majelis Taklim community
Formal Association none

Ceremonies Unable to attend several wedding invitations from her close
relatives
Recreation and leisure Sport None
Hobbies Cooking. Currently, the patient has difficulty cooking complex

meals.
Socializing Patient still often socialized with her neighbors in front of her
house.
Religion and spirituality Sholat 5 times at home, in sitting position
Acquiring, keeping and Part-time employment: she took leave temporary post operation
terminating a job from the job.
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Environmental Factors
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Product and Technology
Products and Technology Items Results
Assistive products and technology for personal Need seating toilet Seating toilet is available.
use in daily living
For personal indoor and outdoor mobility and Wheelchair for mobilization Wheelchair is available
transportation
Car to go to hospital Family’s car is available.
Design, construction and building products and Need products and technology of indoor facilities in design, building and
technology of buildings for public-use construction for public use, such as lifts or elevators, escalators.
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Support and Relationship
Relationship Results
Immediate family Her husband and 2 adult daughters always accompany the patient to the
hospital
Extended family Her cousins and close family give her family support
Friends No data
Personal care providers and personal The patient has 1 maid who helps with her work at home, but the patient
assistants does not yet require personal assistance.
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Services, System, and Policies
Area Items Results
Health services, Health services Rehabilitation facility far from home. The distance is 15 km
systems and policies (45 minutes by car).
Health system Using BPJS for rehabilitation treatment
Health Policies No obstacles yet
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Supporting Examination
GENU DEXTRA GENU SINISTRA

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Intepretation Supporting Examination
o Alignment femorotibial, femoropatella dan proximal tibiofibular baik tidak tampak dislokasi
o Tidak tampak fraktur dan destruksi tulang
o Tampak osteofit pada aspek superopopsterior os patella bilateral, epicondylus lateral, tubercle
lateral os tibia dan os femur bilateral. Tampak pula osteofit pada epicondylus medial os femur dan
os tibia kiri.
o Densitas tulang baik
o Celah sendi femorotibial bilateral menyempit
o Jaringan lunak sekitar kesan baik.
•Kesan : OA genu bilateral grade II.
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Supporting Examination (Post TKA)
• Absent distal os femur dextra dengan
terpasang total knee arthroplasty device,
femoral valgus angle 97, tibial valgus
angle 72.
• Absent proximal os tibia dextra dengan
terapasang total knee arthroplasty
device, femoral flexion angle 6, tibial
flexion angle/slope 86.
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Operation Report
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Diagnosis
Medical Diagnosis • Post Total Knee Arthroplasty Dextra

• Osteoarthritis Genu Sinistra Grade III
• Obesity Grade II
Rehabilitation Diagnosis • Mobilization disturbance

• Right knee pain
• Intrumental - ADL disturbance
• Balance disturbance with risk of falls
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Prognosis
Quo ad vitam : TKA may be associated with mortality and life-threatening complications. Therefore, it is necessary to make an
effort to reduce postoperative complications, and at the same time, it is necessary to determine what risk factors
Bonam
exist. These efforts allow the medical community to optimize the resources used for TKA (Ko et al., 2021).
Quo ad sanationam : After TKA, reliable improvement in pain and function can be expected, and survivorship rates of 90% to 95% after
10 years have frequently been reported. Early failures may result from infection, instability, malalignment, stiffness,
Dubia ad bonam
reflex sympathetic dystrophy, and patellar problems (Maxey et al., 2013).
Quo ad functionam : TKA is a procedure that is capable of providing an overall improvement in patients’ quality of life. This improvement
seems to continue, even six months after the procedure. Pain and function are among the most important
Dubia ad bonam ➔
predictors of improved QOL, even when function remains inferior to that of healthy patients. After total knee
Activity daily life
arthroplasty walking speed for men were 13% slower at normal speed and 17% slower at faster speed. Stair
climbing 51% slower. Men with TKA were 37% to 39% weaker than normal population and performed 36% to 37%
less total work of knee extensors compared to controls. Women with TKA were 28% to 29% weaker and performed
24% less work (Silva et al., 2013)
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Rehabilitation Goals
• Reducing pain
Short-term Goals
• Reducing edema
• Increasing ROM
• Increasing muscle power
• Can walk without assisted

• Maintaining ROM and muscle power
Long-term Goals
• Maintaining patient independency and reducing risk of falls
• Improving ambulation
• Prevent progressivity of the disease

• Improving quality of life
• Managing body weight
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Target-Oriented Rehabilitation Program
No. Problems Goals Programs
1 Pain on the right knee - Reducing pain (NRS < 4) Medicamentosa:
post TKA (NRS 6/10)
- Reducing edema • Natrium diklofenak 50 mg 2x1 (if patient felt pain)
Non medicamentosa:
• Modality:
a. TENS continuous biphasic pulsatile 100 Hz with duration pulse 80
µs, intensity as patient tolerated, 30 minutes, 2x/week
b. Cryotherapy at right genu for 15 minutes, 2x/week
2 ROM Limitation of the - Increasing ROM - AAROM exercise twice / day as patient tolerated
knee
(Flexion 0O -110O ; Extension - CPM beginning with 0O - 90O, and progressing 5O -10O as tolerated
• Flexion 10O-100O 110O -0O) until reach more than 110 O for flexion.
• Extension 100O-10O
3 Muscle Weakness on the - Reducing Pain (NRS < 4) - Isometric strengthening exercise at Quadriceps and hamstring
right knee dextra 2 – 3x/week, 1–3 sets with 8 – 12 repetitions per set with a
- Increasing muscle power
rest interval of 2 – 3 min between sets.
MMT: Flexion 4 ; (MMT > 5)
- Combined with program number 1
Extension 4.
68
Target-Oriented Rehabilitation Program
No. Problems Goals Programs
4 Ambulation Disturbance - Improving ambulation distance (6MWT > 280 M) - Combined with program number 1 – 3
- Walk without assisted
- 6MWT: 280 M - Balance exercise
- Reducing risk of falls: (Berg balance score: medium
- Walk with quadripod risk of falls)
- Improving balance (Standing Dynamic Balance:
- Berg balance score 33/56 (High risk of
adequate)
falls)
- Restore independence with ambulation and balance
5 Pain on the left knee (NRS 2/10) - Maintaining ROM and muscle power (ROM of knee Medicamentosa:
sinistra full ; MMT knee sinistra 5) - Glucosamin 500mg/day
- Prevent progressivity of the disease Non-Medicamentosa:
- ROM exercise genu sinistra
- strengthening exercise at Quadriceps and
hamstring sinistra 2 – 3x/week, 1–3 sets,
40-50% 1-RM with 8 – 12 repetitions per
set with a rest interval of 2 – 3 min
between sets.
6 Obesity grade II - Managing body weight (Target: 69 kg in 3-6 months) - Consult to nutritionist
- Aerobic exercise, 5x/week, moderate
Body weight: 77 kg
intensity (40% - <60% HRR). Duration 30
Body height: 155 cm minutes/day, type A exercise (static
cycling)
BMI: 32 (obese class 2: >30.0)
7 I- ADL Limitation - Improving quality of life by reducing pain and - With achieved program no. 1 - 6
increasing ROM
- WOMAC:45,8%
- WOMAC score > 45,8 %
- Barthel Index: 80/ mild dependency
- Barthel Index : Independent 69
FOLLOW UP
70
1st Evaluation on 30th November 2022
- Pain in the right knee due to post op TKA dextra reducing from NRS 6/10 to NRS 5/10 and was felt less than 5 minutes.
S:
- Pain on the left knee in NRS 2/10 either during activity or not
- The patient refuses to consult a nutritionist, the patient chooses to run her own diet program. The program starts on 14th November
2022. Currently no weight loss from the patient.
• Vital signs
O: o Blood Pressure: 128/82 mmHg ; Heart Rate: 88x/minute ; Respiratory Rate: 20x/minute ; Temperature: 36.6 oC
o Body Mass Index: 32 (Obese class 2: >30,0)
71
Body Function • Knee ROM:
• Flexion: 10-100O ➔10-110O
• Extension: 100-10O ➔ 110-10O
• Knee MMT dextra:
o Flexion: 4 (Pain)
o Extension: 4 (Pain)
• Gait Pattern function:
o Minimal Initial Contact (heel strike).
o Slow speed, decreased cadance
o 2 point gait with quadripod
o Looking downward
o Slight Body sway to the right
o Minimal flexion on preswing on the stance phase
o Wide base
• Standing Dynamic Balance: inadequate
• 6MWT: Improved
• From 280 M (3.53 Mets) ➔ 320 M: 13.58 / 3.5 = 3.88 Mets
• VO2 max = (320 x 0.03) + 3.98 = 13,58 ml/kg/min.
Body Structure o Look:
scar wound post operation (+/-) on anterior midline: edema (-/-), redness (-/-), pus (-/-), Crust (+/-) minimal.
(Structure of lower
o Feel:
extremity)
Warmness (-/-), tenderness (+/-) on operated scar.
o Move:
Crepitation (+/+), limited ROM at knee flexion and extension (Flexion: 10-115O ; Extension: 115-10O)
Tight Circumference: 55 / 58
Calf Circumference: 36 / 39
72
Activities • Changing basic body position:
o Unable to prone, squatting and kneeling.
• Maintaining a body position:
o Unable to maintaining prone, squatting and kneeling position.
• Carrying, moving, and handling objects:
o Unable to putting down the heavy object
o Unable to pushing with right leg
o Unable to kicking with right leg
• Walking and moving
o Only able to walk short distance with quadripod
o Able to moving around within home, outside home and other buildings using equipment (with wheelchair)
o Unable to crawling, climbing, running, jumping, and swimming.
• Moving around using transportation
o Unable to driving
• Household Tasks
o Unable to planning, organizing, cooking and serving meals with a large number of ingredients that require complex methods of
preparation and serving, because the patient is unable to stand for long.
o Unable washing clothes and garments by hand and hanging them out to dry in the air because the patient has difficulty in several
positions that are carried out to wash clothes using assistive devices.
o Unable to mopping floors, cleaning windows and walls, cleaning bathrooms and toilets, cleaning household furnishings.
• Religion and spirituality
o Sholat 5 times at home, in sitting position
• Barthel index 80 (Mild Dependency)
• Womac score 33,3%
• Berg Balance Score 38/56 (medium fall risk)
Environmental • Product and Technology

o Assistive products and technology for personal use in daily living (Need seating toilet, quadripod or wheelchair for mobilization)
Factors o Need products and technology of indoor facilities in design, building and construction for public use, such as lifts or elevators,
escalators. 73
A: Mobilization Disturbance ec Post Total Knee Arthroplasty Dextra + Osteoarthritis Genu Sinistra Grade III + Obesity Grade II
Medicamentosa:
P: • Natrium diklofenak 50 mg 2x1 (if patient felt pain)
• Glucosamin 500mg/day
Non medicamentosa:
• Modality:
• TENS continuous biphasic pulsatile 100 Hz with duration pulse 80 µs, intensity as patient tolerated, 30 minutes, 2x/week
• Exercise:
• AAROM exercise genu dextra twice / day as patient tolerated
• Isotonic strengthening exercise at Quadriceps and hamstring dextra 2 – 3x/week, 1–3 sets with 8 – 12 repetitions per set with a
rest interval of 2 – 3 min between sets.
• ROM exercise genu sinistra
• strengthening exercise at Quadriceps and hamstring sinistra 2 – 3x/week, 1–3 sets, 40-50% 1-RM with 8 – 12 repetitions per set
with a rest interval of 2 – 3 min between sets.
• Aerobic exercise, 5x/week, moderate intensity (40% - <60% VO2R or HRR). Duration 30 minutes/day, type A exercise (static
cycling) 74
2nd Evaluation on 20th December 2022
- Pain at the right knee but decreased from NRS 5/10 to NRS 3/10.
S: - The patient feels that his leg can be straightened.
- Patient can stand a bit longer than before.
- The condition of the left knee still same with previous condition
- Body weight decreased 3kg on a diet program.

• Vital signs
O: o Blood Pressure: 126/80 mmHg ;
o Heart Rate: 84 x/minute ;
o Respiratory Rate: 20 x/minute ;
o Body Mass Index: 30,8 (Obese class 2: >30,0)
75
o Flexion: 10-110O ➔ 0-115O
o Extension: 110-10O ➔ 115-0O
o Flexion: 4 ➔ 5 (Pain)
o Extension: 4 ➔ 5 (Pain)
o Decreased velocity, decreased cadance
o 2 point gait with quadripod
o Looking forward
o Slight body sway to the right, normal arm swing
o No genu varus or valgus, no pelvic obliquity
o Minimal Initial Contact (heel strike), minimal flexion on preswing on the stance phase
o No ankle varus or valgus, wide base
• Standing Dynamic Balance: adequate
• 6MWT: 360 ; Mets: 14.78 / 3.5 = 4.22
• VO2 max = (320 x 0.03) + 3.98 = 14,78 ml/kg/min.

scar wound post operation (+/-) on anterior midline: edema (-/-), redness (-/-), pus (-/-), Crust (-/-).
(Structure of o Feel:
lower extremity) Warmness (-/-), tenderness (+/-) on operated scar.
o Move:
Calf Circumference: 35 / 37 76
o Unable to prone, squatting and kneeling.
o Unable to maintaining prone, squatting and kneeling position.
o Able to putting down the heavy object
o Unable to pushing with right leg
o Unable to kicking with right leg
o able to walk 350m with quadripod
o Unable to driving
• Household Tasks
o Able to planning, organizing, cooking and serving meals with a large number of ingredients that require complex methods of
preparation and serving, because the patient is able to stand a bit longer.
o Unable washing clothes and garments by hand and hanging them out to dry in the air because the patient has difficulty in several
positions that are carried out to wash clothes using assistive devices.
o Able to mopping floors, cleaning windows and walls
o Unable cleaning bathrooms and toilets, cleaning household furnishings.
• Barthel index 80 ➔ 90 (Mild Dependency)
• Womac score 33,3% ➔ 25%
• Berg Balance Score 38/56 ➔ 46/56 (moderate fall risk)
o Assistive products and technology for personal use in daily living (Need seating toilet, quadripod or wheelchair for mobilization)
Factors o Need products and technology of indoor facilities in design, building and construction for public use, such as lifts or elevators,
escalators. 77
A: Mobilization Disturbance ec Post Total Knee Arthroplasty Dextra + Osteoarthritis Genu Sinistra Grade III + Obesity Grade II
P: Medicamentosa:
Non medicamentosa:
• Modality:
- TENS continuous biphasic pulsatile 100 Hz with duration pulse 80 µs, intensity as patient tolerated, 30 minutes, 2x/week
• Exercise:
- AAROM exercise genu dextra twice / day as patient tolerated
- Isotonic strengthening exercise at Quadriceps and hamstring dextra 2 – 3x/week, 1–3 sets with 8 – 12 repetitions per set
with a rest interval of 2 – 3 min between sets.
- strengthening exercise at Quadriceps and hamstring sinistra 2 – 3x/week, 1–3 sets, 40-50% 1-RM with 8 – 12 repetitions per
set with a rest interval of 2 – 3 min between sets.
- Aerobic exercise, 5x/week, moderate intensity (40% - <60% VO2R or HRR). Duration 30 minutes/day, type A exercise (static
cycling)
- Gait training 78
3rd Evaluation on 26th Januari 2023
- Pain at the right knee tolerable with NRS 2/10.
S:
- 2 days before, the patient tried to kneeling but her right knee felt very painful when he stood up.
- No longer using quadripod.
- Able to go up and down stairs. go up the stairs with the healthy leg and go down the stairs with the post operative leg with holding
the rail.
- Body weight decreased 4 kg. (74 kg ➔ 70 kg)

• Vital signs
O:
o Blood Pressure: 130/80 mmHg ; Heart Rate: 80 x/minute ; Respiratory Rate: 20 x/minute ; Temperature: 36.8 oC
o Body Mass Index: 29,1 (Obese class 1: 25 – 29.9)
79
o Flexion: 0-115O ➔ 0-125O
o Extension: 115-0O ➔ 125-0O
o Flexion: 5
o Extension: 5
o Looking forward
• 6MWT: 386 ; Mets: 15.56 / 3.5 = 4.45
• VO2 max = (386 x 0.03) + 3.98 = 15.56 ml/kg/min.

o scar wound post operation (+/-) on anterior midline: edema (-/-), redness (-/-).
(Structure of lower o Feel:
extremity) o Warmness (-/-), tenderness (+/-) on operated scar.
o Move:
o Crepitation (+/+), limited ROM at knee flexion and extension (Flexion: 0-125O ; Extension: 125-0O)
o Special test:
o Patellar grinding test: +/+
80
o Able to prone
o Unable to squatting and kneeling.
o Able to maintaining prone,
o Unable to squatting and kneeling position.
o Able to pushing with right leg
o Able to kicking with right leg
o Unable to driving
• Household Tasks
o Able washing clothes and garments by hand and hanging them out to dry in the air with standing position.
o Able cleaning bathrooms and toilets, cleaning household furnishings.
• Barthel index 90 ➔ 95 (Independent)

• Womac score 25% ➔ 17,7%
• Berg Balance Score 46/56 ➔ 51/56 (low fisk of falls)
o Need products and technology of indoor facilities in design, building and construction for public use, such as lifts or elevators,
Factors escalators.
81
A: Post Total Knee Arthroplasty Dextra + Osteoarthritis Genu Sinistra Grade III + Obesity Grade I
P: Medicamentosa:
Non medicamentosa:
• Modality:
- TENS continuous biphasic pulsatile 100 Hz with duration pulse 80 µs, intensity as patient tolerated, 30
minutes, 2x/week
• Exercise:
• AROM exercise genu dextra twice / day as patient tolerated
• Isotonic strengthening exercise at Quadriceps and hamstring dextra 2 – 3x/week, 1–3 sets with 8 – 12
repetitions per set with a rest interval of 2 – 3 min between sets.
• ROM exercise genu sinistra
• strengthening exercise at Quadriceps and hamstring sinistra 2 – 3x/week, 1–3 sets, 40-50% 1-RM with 8 –
12 repetitions per set with a rest interval of 2 – 3 min between sets.
• Aerobic exercise, 5x/week, moderate intensity (40% - <60% VO2R or HRR). Duration 30 minutes/day, type
A exercise (static cycling)
• Gait training
82
4th Evaluation on 23rd February 2023
S: - Post operative pain at the right knee tolerable with NRS 2/10.
- The patient is back at work.
- The patient is able to walk in the mall with some rest and has attended family events outside the city, at Barru.
- Body weight decreased 4 kg. (70 kg ➔ 66 kg)
O: • Vital signs
o Blood Pressure: 130/80 mmHg
o Heart Rate: 80 x/minute
o Respiratory Rate: 20 x/minute
o Body Mass Index: 27,5 (Obese class 1: 25 – 29.9)
83
o Flexion: 0-125O
o Extension: 125-0O
o Flexion: 5
o Extension: 5
o Looking forward

scar wound post operation (+/-) on anterior midline: edema (-/-), redness (-/-).
(Structure of lower o Feel:
extremity) Warmness (-/-), tenderness (+/-) on operated scar.
o Move:
84
Gait Examination
85
o Able to prone and kneeling.
o Unable to squatting.
o Able to maintaining prone and kneeling position.
o Unable to squatting position.
o Able to pushing with right leg
o Able to kicking with right leg
o Able to moving around within home, outside home and other buildings.
o Unable to driving
• Household Tasks
o Able washing clothes and garments by hand and hanging them out to dry in the air with standing position.
o Able cleaning bathrooms and toilets, cleaning household furnishings.
• Barthel index 95 (Independent)

• Womac score 17,7% ➔ 14,6%
• Berg Balance Scale 51/56 ➔ 54/56
o Need products and technology of indoor facilities in design, building and construction for public use, such as lifts or elevators,
Factors escalators.
86
Post Total Knee Arthroplasty Dextra + Osteoarthritis Genu Sinistra Grade III + Obesity Grade I
A:
P: Medicamentosa:
Non medicamentosa:
• Modality:
- TENS continuous biphasic pulsatile 100 Hz with duration pulse 80 µs, intensity as patient tolerated, 30
minutes, 2x/week
• Exercise:
- AROM exercise genu dextra twice / day as patient tolerated
- Isotonic strengthening exercise at Quadriceps and hamstring dextra 2 – 3x/week, 1–3 sets with 8 – 12
repetitions per set with a rest interval of 2 – 3 min between sets.
- strengthening exercise at Quadriceps and hamstring sinistra 2 – 3x/week, 1–3 sets, 40-50% 1-RM with 8 –
12 repetitions per set with a rest interval of 2 – 3 min between sets.
- Aerobic exercise, 5x/week, moderate intensity (40% - <60% VO2R or HRR). Duration 30 minutes/day, type
A exercise (static cycling)
- Gait training
87
Summary of Improvement
1st Examination 1st 2nd 3rd 4th Intepretation of the
Result
Follow Up Follow Up Follow Up Follow Up
Pain (NRS) 6/10 5/10 3/10 2/10 2/10 Goal achieved
ROM F: 10-100 F: 10-110 F:0-115 F:0-125 F:0-125 Goal achieved
E: 100-10 E: 110-10 E:115-0 E:125-0 E:125-0
MMT F: 4 ; E: 4 F: 4 ; E: 4 F: 5 (P) ; E:5 (P) F: 5 ; E: 5 F: 5 ; E: 5 Goal achieved
6MWT 280 m ; 320 m; 360 m; 386 m; 398 m; Goal achieved
3,53 Mets 3,88 Mets 4,22 Mets 4,45 Mets 4,55 Mets
Tight Circumference D: 55 D: 55 D: 53 D: 54 D: 54 Improvement
S: 58 S: 58 S: 55 S: 55 S: 55
Calf Circumference D: 35,5 D: 36 D: 35 D: 35 D: 35 Improvement
S: 39 S: 39 S: 37 S: 36 S: 36
Barthel Index 80 (Mild 80 (Mild 90 (Mild 95 (Independent) 95 (Independent) Goal achieved
Dependency) Dependency) Dependency)
Womac Score 45,8% 33,3% 25% 17,7% 14,6% Decreased 31,2%
(Improvement)
Berg Balance Scale 33 (High Risk of 38 (Moderate 46 (Moderate Risk of 51 (low Risk of 54 (low Risk of Decreased 21 poin
Falls) Risk of Falls) Falls) Falls) Falls) (Goal achieved)
Body Weight 77 kg 77 kg 74 kg 70 kg 66 kg Decreased 11
kilograms at 4 months
BMI: 32 BMI: 32 BMI: 30,8 BMI: 29,1 BMI: 27,5
(Improvement)
CASE ANALYSIS
89
THANK YOU
BMI
91
92
Perilaku Biomekanis dan Viskoelastik
Kartilago Artikular
•BEBAN
• Perubahan molekul PG
• Peningkatan tekanan cairan

interstisial → cairan akan
mengalir keluar → konsentrasi
proteoglikan meningkat
• Kolagen (kuat saat ditarik,

melemah saat dikompresi)
93
Kartilago Artikular
94
95

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LONG CASE

Mobilization Disturbance ec Post Total

PPDS : dr. Advendila Margaretha Artz

SPV : dr. Mathilda Albertina, Sp. K.F.R

Osteoartritis merupakan penyebab utama morbiditas dan

Prevalensi osteoartritis pada perempuan Indonesia mencapai 8,5% dan laki-laki

➢ Penyebab dan perkembangan OA lutut ➔ perubahan dramatis dalam

➢ Fungsi tulang rawan :

Recruitment Dibersihkan oleh

Berbagai jenis dan kedalaman

1. Cedera tipe 1 (dangkal)

2. Cedera tipe 2 (ketebalan parsial)

3. Cedera tipe 3 (full-thickness)

(nyeri lutut + 3 dari 6 poin)

• Usia > 50 tahun • Tidak teraba adanya panas

(nyeri lutut + 1 dari 3 poin)

Fiksasi prostesis TKA

Gold standard teknik fiksasi ➔ Cemented

PPDS : dr. Advendila Margaretha Artz

• Pain decreased at rest with NRS 2/10.

• The patient felt the legs still swollen.

➢ History of family illness:

The patient is taking postoperative medication from orthopedics:

o Thorax: Simetris, no retraction.

o Lung: Normal vesiculer sound, no wheezing or ronchi.

o Cor: S1-S2 sound reguler, no murmur, no gallop.

o Abdomen: Normal peristaltic sound, liver and spleen unpalpable.

o Extremities: Acral warm, no edema, CRT < 2 second.

• Standing static balance adequate

• Sitting dynamic balance adequate

• Standing dynamic balance inadequate

Kinaesthesia Not tested Could sense joint movement

Function Items Results

Respiration function Respiration rate 20 x/minute

Respiratory rhythm Normal, rhythmic

Depth of respiration Single Breath Count Test 35

Function Items Results

Function Items Results

BMI : 32 (obese class 2: >30.0)

Flexion 10 – 100 (Pain) 0 – 135

Muscle group Right Left

Repair functions of the open wound (-), Crust (+)

skin such as itching,

Structure of lower extremity Right Left

Bones of lower leg ALL: 98 ALL: 98

Muscles of lower leg Thigh circumference: 55 Thigh circumference: 58

Calf circumference: 35,5 Calf circumference: 39

Activity area Result

Lifting and carrying objects Able

Fine hand use Able

Hand and arm use Able

Carrying on shoulders, hip and back Able

Putting down objects Unable to putting down the heavy object

Pushing with lower extremities Unable to pushing with right leg

Kicking Unable to kicking with right leg

Outside the home and other Unable

transportation public transportation (bus)

Driving Driving human-powered Unable

Driving motorized vehicles Unable

21-40 Severe Dependency

Formal Association none

Hobbies Cooking. Currently, the patient has difficulty cooking complex

use in daily living