Rehabilitation guidelines for patients undergoing knee arthroscopy

At the RNOH, our emphasis is patient specific, which encourages recognition of those who may progress slower then others. We also want to encourage clinical reasoning.

Milestone driven
These are milestone driven guidelines designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the Outpatient Clinic at RNOH by helping the patient and therapist identify when specialist review is required.

Team:
Professor Briggs secretary: Mr Pollocks secretary: Mr Carringtons secretary: Mr Miles secretary: Mr Skinners secretary: Physiotherapy department: 020 8909 5573 020 8909 5677 020 8909 5618 020 8909 5831 020 8909 5621 020 8909 5820/5519

Indications for surgery:

Meniscal tears Damage to the articular cartilage of the joint Debridement Loose body within the knee Synovectomy Ligament reconstruction Repairing certain joint fractures Biopsy

Incision:
A knee arthroscopy is a procedure that involves making two or three small incisions, or portals, usually in front of the knee. A small arthroscope (three to five millimetres in diameter) is inserted into the knee allowing the surgeon to see and operate inside the joint. Knee arthroscopy is usually carried out under a general anaesthesia, either as a day case or in some instances as an overnight stay in hospital.

Possible complications of surgery:

Accidental damage to the knee joint Bleeding Nerve damage Deep Vein Thrombosis Pulmonary embolism Persistent/recurrent pain

Knee arthroscopy Guidelines 2010

Review 2012

Infection

Pre-operatively:
Where possible the patient will be seen pre-operatively and, with consent, the following assessed: Current functional levels General health Social/work/hobbies Functional range of movement Gait/mobility, including walking aids, orthoses Muscle power and range of movement Post-operative expectations

Treatment:
Patient information leaflet issued Swelling management Exercises: taught as per handout (see Appendix A) Gait re-education: ensure safe and independently mobile with appropriate walking aid/s Mobility: ensure patient is independently mobile, including stairs if necessary Advice/education: teach how to monitor sensation, colour, circulation, temperature, swelling, and advise what to do if concerned. Teach protection, rest, icing, compression and elevation (PRICE) Post-operative management explained, especially self-management at home after discharge

Patient treatment plan completed and filed in medical notes. Patient discharged unless indications to be seen post-operatively.

Post-operatively
Patients are not routinely seen post operatively unless requested by the medical team (i.e. ACL deficient/rupture). The patient should mobilise FWB (unless stated otherwise) once they have had something to eat and drink. Exercises as should be commenced as per Appendix A. No further physiotherapy treatment should be necessary. The medical team will refer for outpatient physiotherapy if appropriate.

Knee arthroscopy Guidelines 2010

Review 2012

Recovery rehabilitation phase: 0 weeks 2 weeks

Return to work
If patients job involves sitting for the majority of the day they can return after 3 days. If their job is physically demanding and involves heavy manual work or standing for long periods then 1-2 weeks off work may be necessary.

Driving
Patients should not return to driving until their knee is pain free and they have full knee flexion. They MUST be able to perform an emergency stop, and should inform their insurance company about the surgery to ensure their cover is valid.

Mobility
The patient can mobilise FWB immediately post operatively. They may use crutches until the knee becomes more comfortable, usually 2-3 days.

Wound care
The stitches or steristrips will be removed at clinic if the patient is seen 2 weeks or less post operatively. Otherwise the patient should have been advised what to do by the ward staff. The wound should be kept clean and dry to prevent infection If there is excessive bleeding through the dressing, the patient should contact the ward, GP or local A&E department for advice

Knee arthroscopy Guidelines 2010

Review 2012

Failure to progress
If a patient is failing to progress, then consider the following:

Possible problem Swelling

Pain

Breakdown of wound e.g. inflammation, bleeding, infection Recurrent instability

Action Ensure elevating leg regularly Use ice as appropriate if normal skin sensation and no contraindications Decrease amount of time on feet Pacing Use walking aids Circulatory exercises Modify exercise programme as appropriate. Should continue isometric work at all times If decreases overnight, monitor closely If does not decrease over a few days, refer back to surgical team Decrease activity Ensure adequate analgesia Elevate regularly Decrease weight bearing and use walking aids as appropriate Pacing Modify exercise programme as appropriate. Should continue isometric work at all times If persists, refer back to surgical team Refer to surgical team

Numbness/altered sensation

Refer back to surgical team Ensure exercise progressions are at suitable level for patient Address core stability Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team If static, monitor closely, but inform surgical team and refer back if deteriorates or if concerned

Knee arthroscopy Guidelines 2010

Review 2012

Exercises to be started immediately after your knee arthroscopy

2.

1. Lying on your back with a sliding board under your leg. Bend and straighten your hip and knee by sliding your foot up and down the board. Keep your kneecap and foot facing the ceiling throughout. Repeat 15 times, 3-4 times daily

2. Lying on your back or sitting up in bed with legs straight. Bend your ankles and push your knees down firmly into the bed. Hold 5 seconds - relax Repeat 20 times, 3-4 times daily

3. Lying on your back or sitting up in bed. Put a roll under your operated leg. Exercise your operated leg by pulling your foot and toes up, tightening your thigh muscle and straightening the knee (keep knee on roll). Hold approx. 5 seconds and slowly relax. Repeat 20 times, 3-4 times daily

4. Sitting on a chair or the edge of the bed with your foot on a sliding board. Bend your knee as much as possible. Hold for 5 seconds and slowly relax your leg. Repeat 15 times, 3-4 times daily

Knee arthroscopy Guidelines 2010

Review 2012

Exercises to be started 3 days after your knee arthroscopy

1. Sit on a chair or on the edge of the bed. Pull your toes up, tighten your thigh muscle and straighten your knee. Hold approx. 5 seconds and slowly relax your leg. Repeat 20 times, 3-4 times daily

2. Sit on a chair or edge of the bed with your feet on the floor. Bend your knee back as much as possible. Hold for 5 seconds. Repeat 20 times, 3-4 times daily

3. Lying face down with your hips straight and knees together. Bend your knee as far as possible keeping the hip straight and ankle flexed. Hold approx 5 seconds. You can do the exercise with a 5kg weight or rubber exercise band around the ankle. Repeat 20 times, 3-4 times per day

4. Lying on your back with one leg straight and the other leg bent (you can vary the exercise by having your foot pointing either upwards, inwards and outwards). Exercise your straight leg by pulling the toes up, straightening the knee and lifting the leg 20cm off the bed. Hold approx. 5 seconds- slowly relax Reference Repeat 15 times, List 3-4 times daily

Knee arthroscopy Guidelines 2010

Review 2012

Summary of evidence for physiotherapy guidelines

1. Goodwin et al, Physiotherapy after arthroscopic partial meniscectomy surgery: an assessment of costs to the National Health Service, patients, and society. Int J Technol Assess Health Care. 2005 Fall;21(4):452-8.PMID: 16262967 Providing clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is more costly to the NHS and patient, but no more costly to society than when not providing it and does not result in reduced contact with the NHS. CONCLUSIONS: Clinicbased physiotherapy after knee arthroscopic partial meniscectomy surgery is costly and evidence is needed that its effectiveness is high enough to support its use. 2. Goodwin PC & Morrissey MC. Physical therapy after arthroscopic partial meniscectomy: is it effective? Exerc Sport Sci Rev. 2003 Apr;31(2):85-90. Studies reviewed in this paper show there is little evidence that formal physical therapy is necessary to return patients to their normal receiving this care. 3. Goodyear-Smith F, Arroll B. Rehabilitation after arthroscopic meniscectomy: a critical review of the clinical trials. International Orthopaedics. 2001; 24(6): 350-353 In most cases, simple analgesics in the first 1 to 2 days following surgery and a wellplanned home-based exercise programme should be sufficient for recovery. One study found that physiotherapy was beneficial for retaining muscle strength and had a positive effect on pain assessment, but this did not translate into functional improvement. 4. Morrissey et al, Evaluating treatment effectiveness: benchmarks for rehabilitation after partial meniscectomy knee arthroscopy. American Journal of Physical Medicine & Rehabilitation (AM J PHYS MED REHABIL), 2006 Jun; 85(6): 490-501 Quick recovery occurs in these patients when only a home exercise program is given. 5. NHS Choices Knee Arthroscopy 25/08/2009 http://www.nhs.uk/conditions/Arthroscopy/Pages/Introduction.aspx 6. NICE Guidelines (2006) Interventional procedure overview of arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis http://www.nice.org.uk/IPG230 7. Rodriguez Moreno HA et al, Risk of deep vein thrombosis in patients undergoing knee arthroscopy. Current Orthopaedic Practice, 2009 Nov-Dec; 20 (6): 665-8 (journal article - equations & formulas, research, tables/charts) ISSN: 1940-7041 CINAHL AN: 2010473193 8. SM Coppola & SM Collins. Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review. The Knee, volume 16, issue 3, Pages 171-175 (June 2009) - Elsevier In select young and healthy population with few co morbidities supervised physical therapy is no more beneficial than a home exercise program following relatively simple knee surgical procedures (arthroscopic meniscectomy).

Knee arthroscopy Guidelines 2010

Review 2012