Prehabilitation for knee replacement

PIG Meeting: 22nd April 2021

64-year-old lady for a Left TKR. Currently housebound and immobile following right TKR.

Background

  • Right TKR in 2018 complicated by femoral condyle fracture intraoperatively
  • Partial weight-bearing postoperatively and unable to participate in rehabilitation
  • Currently housebound, no physical activity
  • Multiple previous postponements from perioperative clinic and one cancellation on day of surgery for medical optimisation

Issues

  • Morbidly obese, BMI 50
  • Very complex social situation, husband working full time and is her carer
  • Bilateral rotator cuff tears – may not be able to use forearm support frame postoperatively
  • Attended rehabilitation last year and engaged well with services
  • Lost 30kg with diet and exercise program
  • Stopped attending due to distance – patient is from Taree and was travelling to Newcastle
  • Poor understanding of perioperative risk.
  • Patient and husband very keen for surgery to proceed

Discussion

1. Should surgery proceed?

  • High risk for postoperative complications including joint infection
  • Unlikely to be physically fit to participate in rehabilitation in current condition
  • Surgical team unaware of booking for surgery and thought ‘she hadn’t been cleared by anaesthetics to proceed.’

2. Can this patient be optimised preoperatively?

  • Immobility – re-engage with physiotherapy and rehabilitation services
  • Previous effective weight loss with dietician input, new referral
  • Social issues, is husband struggling to cope? Would help from outside the home alleviate some stressors?
  • Consider home modifications to help patient to manage ADL’s alone

Plan

  • Multi-disciplinary input required from physio, OT, dietician, and social work.
  • Review in 6 weeks

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