Vanderbilt Orthopaedic InstituteTotal Knee Arthroplasty (TKA) and Unicondylar Rehabilitation GuidelinePre-operative Phase RecommendationsGOALS: Attend pre-operative group education class Maintain and/or increase strength and ROM Education of patient on rehab and expectations Normalize gait as much as possible (use cane or walker if appropriate) All exercises should be performed 20x 5 second hold 2x/day unless otherwise statedo Ankle Pumpso Gluteal Setso Hamstring Setso Quad Setso Straight Leg Raise (SLR)o Short Arc Quads (SAQ)o Hamstring Stretch: 5 x 20 second holdPost-operative PhasesContra-indications: no resisted wt machines until week 6 post op. (unless otherwise notedper MD. Check prescription, post op note/discharge summary)Precautions: Optimal ROM should be 110-125 degrees flexion and 0 degrees extensionbefore beginning weight resisted machines. If knee flexion PROM is too aggressive abnormalheterotopic bone on the femur may develop. *Be aware of s/s of a DVT*General Information: During documentation use only the TKA evaluation, the standard dailynote, the TKA progress note and discharge templates. Staples come out 10-14 days aftersurgery. Blood draws for coumadin are on done on Mondays and Thursdays for 21 days aftersurgery. Optimally PT is daily x 2 weeks or until 115 degrees flexion and 0 degrees extension,then 3 days/week until return to clinic (RTC/MD appointment) at 6 weeks. Bilateral kneesmight require 6-8 weeks of PT. The guidelines have been developed to service the spectrum ofTKA patients, including unicompartmental replacements. For this reason, approximate timeframes post-operatively and example exercises are provided instead of a highly structuredrehabilitation program. The attending rehabilitation specialist should tailor the program to eachpatient’s specific needs. It is recognized that some patient’s health plans may limit theircovered PT, and the program will be adjusted as able. VOI fitness access: 50 for 3 monthstotal.Contacts:Dr. Shinar: e-mail or star panelNP: Carolyn Aubrey: 4-0836/e-mailDr. Calendine: (VBJ) e-mailRN: Sandra Shoemake: 790-3290 ext 142Dr. Holt: e-mail or star panelNP: Annabell Atkinson: 835-5315/e-mailOrtho Outpatient Clinic: 3-5599 (to find MDs when in clinic)Social Workers: Ginger Ketschke (round wing) 835-5928(May need to contact the social worker if you can’t get in touch w/pt for contactinformation or if the plan of care has changed)1/21/2011

Vanderbilt Orthopaedic Institute*If ONE visit is cancelled or not kept call the patient that day to find out why. Make sure to getthem in ASAP. If you can’t get in touch with them contact the social worker or the NP. If theycan’t come in they may need home health rehab.Outpatient Day 1- (Day of Outpatient Evaluation)GOALS: Complete initial post-operative evaluation with functional measures (use TKA template) Knee ROM 0 to 90 Healthy incision: If incision is abnormally red contact NP to come and inspect Progress knee ROM, neuromuscular re-education / strengthening, control swelling;Note: Suggested exercises listed below given for home exercise program (HEP)o Seated knee flexion stretch and/or wall slides (supine 90/90)- (contract/relaxtechnique, slow and controlled ( 30 sec holds to change scar tissue))o Quad set (with towel roll/blood pressure cuff; heel on towel roll for stretch)o SLR- (SLR w/o knee flexion lag)o TKE/SAQo Hamstring stretch/seated hamstring and dorsiflexion stretch w/towelo Gait training with walker: focus on knee extension, quad contraction and knee flexiono Iceo Coumadin draws on Monday/Thursday- prepare lab sheets (check forms on theexercise hand out wall; go to sport medicine desk to get the pt info printed on theform)- lab is on 7th floor MCE North. (For outside referrals they may need blooddraws at Vandy as well. Clinician will have to call referring MD with results that dayof draw. May find results in Star Panel under Lab tab.Outpatient Day 2- Day 10: PT 3-5x/weekGOALS: Remove staples at 10-14 days after surgery and apply steristrips Patient education: scar massage at day 10 post-op or after staples/steristrips removed Knee ROM: when 0 to 115 degrees attained reduce PT to 3x/wk Strong quad set Progress knee ROM, total leg neuromuscular re-education / strengthening, and controlswellingo Modalities: Moist heat (PRN) before, NMES (PRN), ice after Rxo Continue above exercises as indicated and gait trainingo Prone hangs (after staples are out; towel roll proximal to patella for comfort/ROM)o Total leg AROM / PROM / Joint and soft tissue mobilization (PRN)o Bridging progression and calf strengtheningo Hip strengthening: Supine hooklying Adduction with ball between the knees,Clamshell with theraband (TB) proximal to kneeo Hamstring curls sitting with TheraBando Bike- 5-10 min (Upright, Recumbent or Biostep)o Coumadin Monday/Thursday- prepare lab sheets- lab is on 7th floor MCE North1/21/2011

Vanderbilt Orthopaedic InstituteOutpatient Day 10-Day 21: PT 2-5x/week depending on ROMGOALS: ROM 0 to 115: If ROM goal not met contact MD/NP b/c manipulation may be indicated Evaluate and treat proximal and distal joints for mobility, flexibility and strength Improve gait for progression from walker to cane Normalize sit to stand mechanics Progress knee ROM, ambulation and strength, initiate dynamic stability exercises,introduce closed kinetic chain (CKC) exerciseso Bike- 5-15 min at beginning of Rxo Continue above exercises and manual therapy as indicated and gait trainingo 4-way SLR (on mat or standing with TheraBand/cuff weight progression)o Hamstring curls (with TheraBand progression) (seated or prone)o TKE standing with TheraBand or single pulleyo Closed Kinetic Chain exercises: Standing Wall squats (0-45 degrees); Step-ups- 2”(focus on knee positioning) and stair trainingo Gait training: focus on knee extend/quad contraction and knee flexion; progress tocane when appropriate; backwards/heel walking to facilitate knee extensiono Balance: Single Leg Stance, tandem walk, side steps, weight shifts, hurdleso Coumadin until day 21 after surgery.o IceOutpatient Week 3-6: PT 1-3x/week depending on state of recoveryGOALS: Maintain ROM, progress total leg strength, dynamic stabilization and gait activities,educate regarding lifelong fitness / maintenance of healthy lifestyle, prepare fordischarge to independent exercise program (preferably at VOI fitness center or otherfitness / wellness facility of patient’s choice). Wean away from assistive device during gait when appropriate/safe. If patient has not achieved 115 knee flexion ROM by week 4, please contact NP/MDo Bike , summit trainer, elliptical, biostepo Continue above exercises and manual therapy as indicated and gait trainingo Knee flexion/extension stretches PRN and discontinue if knee ROM 0-120 or o Progress stair and gait training, wean away from assistive device (ifappropriate/safe)o Progress balance exercises: SLS (Folded towel, wobble board, Dynadisc, bosu)o Progress step-ups to 4” or 6” (with correct knee positioning and control duringconcentric and eccentrico Progress static hold for standing wall squats (0-60 degrees)o Resisted tandem walking / side-stepping (with sport cord if patient is ambulatorywithout assistive device)1/21/2011

Vanderbilt Orthopaedic Instituteo Life Fitness / Hammer Exercise Machines (Begin no sooner than Week 6)o Parameter for progressing to weight machines:1. Patient able to complete green TheraBand with resistance exercises2. Determination made to use Life Fitness vs. Hammer based onindividual patient needs and general health status: Perform a 1rep max/8 rep max test to determine safe level tobegin weights on machines. Then begin at 70% of 8RM forreps at next session.o Knee flexion/ extension, Leg Press, Hip Adduction / Abduction and Extension,Calf Extensiono Instruct patient in machine settings and if patient interested, enroll in VOIFitness Center ( 50 for 3 months total). Give Fitness booklet to patient withsettings to take to VOI.o Ice as neededo Week 6: typically return to driving, but per MDAdvanced Phase beyond week 6:GOAL: Long-term fitness program to maximize the survivorship of your new joint Progress out of outpatient PT to home program/independent fitness program Advance and continue leg Functional strength and endurance Flexibility and balance Focus on quality of exercises and avoid compensations Higher level training/Sports activities if appropriate Aquatics based exercises if accessible Acceptable activities: swimming, biking, walking, dancing, golfing and bowling Lifelong restrictions NO high impact activities (for example: running and jumping) No continual carrying heavy loads 40 pounds (for example: 20 times a day, 5days a week. Occasional lifting IS allowed Travel guidelines: see total joint booklet1/21/2011

Vanderbilt Orthopaedic Institute1/21/2011

Vanderbilt Orthopaedic InstituteSummary of the 2010-2011 Modifications to the Total Knee Replacement Guidelines Format changes for easier reading Due to changes in insurance limitations, more flexibility notedw/frequency of physical therapy attendance (i.e.: 3-5x/wk vs. 5x/wk) Page 1 is now a summary of pre-operative and post-operativeexpectations and information, along with contact information for totaljoint physicians, nurse practitioners and social workers. Each post-operative time phase has specific ROM goals and morevariability in treatment options to allow for each patients specific needs,while respecting recovery time and precautions/contra-indications. Further guidelines were listed for care past the 6 week mark ofsurgery, for improved long-term recovery. Some of these modifications were incorporated from Dr. Calendine’sTKA guideline All precautions and contra-indications remain the same. Unless notedby the surgical team (MD or NP) weight machines will only begin afterweek 6 post-operatively.1/21/2011

Vanderbilt Orthopaedic Institute 1/21/2011 Outpatient Day 10-Day 21: PT 2-5x/week depending on ROM GOALS: ROM 0 to 115: If ROM goal not met contact MD/NP b/c manipulation may be indicated Evaluate and treat proximal