Delayed ambulation after total knee arthroplasty (TKA) decreases pain and swelling and facilitates recovery without increasing complications, according to a Shelbourne Knee Center study.1
"One of the most important aspects of patient recovery post-TKA is being able to tolerate physical therapy,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. “Our study showed that bedrest during days 1–7 post-op, when done the right way, facilitates improved range of motion and leg control without increasing common complications."
Results Support Bedrest
The study, conducted by Sarah Eaton, PT, DPT, ATC, LAT, and Dr. Benner, involved 641 TKAs in 463 patients performed by Dr. Benner between 2012 and 2018:1
- 285 unilateral TKAs
- 95 bilateral TKAs (190 knees)
- 83 staged bilateral TKA (166 knees).
Eaton and Dr. Benner identified 22 complications in 20 patients (3.4%):1
- Deep vein thrombosis (DVT): 2 (0.3%)
- Joint infections: 4 (0.6%)
- Manipulations under anesthesia (MUA) for flexion loss: 5 (0.8%)
- Scar resections for extension loss: 2 (0.3%)
- Heart/lung related problems: 6 (0.9%)
- Hospital re-admission for pain: 1 (0.2%)
- Medial femoral condylar fracture: 1 (0.2%)
- Patellar dislocation: 1 (0.2%).
Shelbourne Knee Center’s rates of DVT, infection and MUA were lower than or similar to those seen in the current literature.1
“We assumed that our complication rate was as low or lower than average,” says Eaton. “Now when patients and caregivers ask us about the rate of specific complications, we can use these data to answer those questions.” Eaton is one of nine physical therapists and athletic trainers at Shelbourne Knee Center.
Better ROM and Less Stiffness
The range of motion (ROM) loss of < 1% for Shelbourne Knee Center patients is lower than the rate seen in the current literature. A systematic review by Zachwieja et al. reported a 1.3–5.8% prevalence rate of stiffness after TKA.7
Average ROM for Shelbourne Knee Center patients was:
- One-week postoperatively: 0-2-104 degrees
- Two-weeks postoperatively: 0-1-112 degrees
- One-month postoperatively: 0-0-117 degrees.
“Our study showed that putting TKA patients on bedrest for the first seven days postoperatively improved recovery of ROM,” says Dr. Benner.
Sharing Research Results
Eaton presented a poster about the study at the Indiana American Physical Therapy Association virtual conference in September 2020. She also did a poster presentation at the virtual national combined sections meeting of the American Physical Therapy Association in February 2021.
Rehab Begins During Bedrest
The TKA postoperative rehabilitation protocol is based on research on Shelbourne Knee Center’s ACL patients, which showed the importance of improving ROM before strengthening.10 TKA patients begin rehabilitation during the seven-day bedrest period, with the goals of decreasing swelling, increasing ROM, promoting normal leg control and promoting normal gait with an assistive device.
Patients wear TED hose and use a Knee Cryo/Cuff and a continuous passive motion (CPM) machine with the knee elevated. The Knee Cryo/Cuff provides compression and cold therapy to help control swelling. K. Donald Shelbourne, MD, an orthopedic surgeon at Shelbourne Knee Center, developed the device in collaboration with Aircast.
To minimize swelling, patients only walk to the bathroom. Three times daily, they perform physical therapy exercises to maximize ROM and maintain proper quadriceps/leg control. A personal physical therapist or athletic trainer guides each patient through rehab. “Specializing in knees enables us to provide expert and consistent care,” says Eaton.
- Eaton S and Benner R. Effects of 1-week Bedrest on Complication Rate and Range of Motion following Total Knee Arthroplasty. Presented at the Indiana American Physical Therapy Association virtual conference, September 2020. Lee SY, Ro DH, Chung CY, Lee KM, Kwon SS, Sung KH, Park MS. Incidence of deep vein thrombosis after major lower limb orthopedic surgery: analysis of a nationwide claim registry. Yonsei Med J. 2015 Jan; 56(1): 139-145.
- Dua A, Desai SS, Lee CJ, Heller JA. National trends in deep vein thrombosis following total knee and total hip replacement in the United States. Ann Vasc Surg. 2017 Jan; 38: 310-314.
- Dai WL, Lin ZM, Shi ZJ, Wang J. Venous thromboembolic events after total knee arthroplasty: which patients are at a high risk? J Knee Surg. 2019 May; 24: doi: 10.1055/s-0039-1688962.
- Teo BJX, Yeo W, Chong HC, Tan AHC. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong). 2018 May-Aug; 26(2): 2309499018785647.
- Anis HK, Mahmood BM, Kilka AK, Barsoum WK, Molloy RM, Hiquera CA. Hospital volume and postoperative infections in total knee arthroplasty. J Arthroplasty. 2020 Apr; 35(4): 1079-1083.
- Zachwieja E, Perez J, Hardaker WM, Levine B, Sheth N. Manipulation under anesthesia and stiffness after total knee arthroplasty. JBJS Reviews. 2018 Apr; 6(4): e2.
- Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015 Sep; 30(9)(Suppl): 72-5.
- Issa K, Rifai A, Boylan MR, Pourtaheri S, McInerney VK, Mont MA. Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty? Clin Orthop Relat Res. 2015 Jan; 473(1): 143-147.
- Biggs A, et al. Rehabilitation for patients following ACL reconstruction: A knee symmetry model. North Am J Sports Phys Ther. 2009;4:2-12.