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Total Knee Replacement (TKR): Surgical Approaches & Physiotherapy Protocol

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PART 1 - SURGICAL APPROACHES FOR TKR

1. Medial Parapatellar Approach (Most Common - "Gold Standard")

• Incision: Midline longitudinal skin incision from 5-8 cm above the patella to the tibial tuberosity
• Arthrotomy: Medial to the quadriceps tendon, along the medial border of the patella, extending to the medial aspect of the tibial tuberosity
• Patella: Everted and subluxed laterally for exposure
• Advantages: Excellent exposure, familiar to all surgeons, works for virtually all knee sizes and deformities
• Disadvantage: Disrupts the quadriceps tendon insertion; potential for patellar devascularization; associated with more postoperative quad weakness
• Note: If using this approach for TKR with a non-resurfaced patella, repair of the medial patellofemoral ligament is recommended at closure to prevent medial capsular dehiscence and lateral patellar facet loading (Campbell's Operative Orthopaedics 15e)

2. Subvastus (Southern) Approach

• Concept: The vastus medialis muscle is elevated from the intermuscular septum and reflected medially, leaving the quadriceps mechanism intact
• Advantage: Preserves vascularity of the patella by sparing the intramuscular articular branch of the descending genicular artery; preserves the quadriceps tendon - leads to faster quad recovery and earlier straight leg raise capability
• Contraindications (from Campbell's 15e):
  • Prior major knee arthroplasty
  • Patient weight >200 lb (~90 kg)
  • Thigh girth >55 cm (patella cannot be everted)
• Best for: Thin patients without prior surgery who need optimal patellar tracking

3. Midvastus Approach

• A compromise between parapatellar and subvastus approaches
• The vastus medialis oblique (VMO) is split along its fibers (usually 1-2 cm)
• Better exposure than subvastus but less disruption than full parapatellar
• Good for moderate body habitus

4. Lateral Parapatellar Approach

• Used for severe valgus deformity (>15-20°)
• Allows direct access to contracted lateral structures
• Patella subluxed medially
• Less commonly used but preferred by some surgeons for severe deformity correction

5. Tibial Tuberosity Osteotomy (TTO)

• Used as a salvage exposure when quadriceps contracture prevents adequate exposure through standard approaches (e.g., in stiff knees, revision TKA)
• The tuberosity is osteotomized, the extensor mechanism is reflected proximally, then reattached with screws
• From Campbell's: "This technique achieves rigid fixation and allows early postoperative rehabilitation"

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PART 2 - PHYSIOTHERAPY PROTOCOL FOR TKR

PREHABILITATION (Pre-operative)

• Strengthen quadriceps, hamstrings, hip abductors
• Improve baseline ROM
• Patient education on exercises and expectations
• Optimize weight, cardiovascular fitness

• Quad sets, SLR, mini-squats, hip abduction
• Aerobic conditioning (cycling, swimming)
• Education: postoperative precautions, gait aid use, VTE prevention

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PHASE I - EARLY INPATIENT (Day 0-3)

• Reduce swelling and pain
• Achieve PROM 0-90°
• Quad strength ≥3+/5
• Independent ambulation with rolling walker (full weight bearing as tolerated)
• Safe bed mobility and transfers

• Do NOT sleep with pillow under the knee (promotes flexion contracture)
• Position knee in full extension when at rest (towel/pillow under calf)
• Do NOT sleep in a recliner with knees bent

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PHASE II - EARLY OUTPATIENT (Days 3 to Week 4)

• AROM 0-120°
• Knee extension strength ≥4/5
• Independent SLR without extensor lag
• Independent ambulation, weaning assistive device
• Stair negotiation (step-to pattern)

• Cryotherapy post-exercise
• TENS/electrotherapy for pain
• Manual lymphatic drainage and Kinesio taping for persistent swelling

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PHASE III - INTERMEDIATE (Weeks 4-8)

• AROM symmetrical to contralateral limb
• Quadriceps Index ≥85%
• Pain-free ADLs
• Independent ambulation without device
• Swelling <2 cm difference from opposite limb

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PHASE IV - ADVANCED (Weeks 8-12)

• Swelling <1 cm of contralateral limb
• Quadriceps Index ≥90%
• Pain-free with moderate recreational activity
• Unrestricted ambulation distance

• Resisted squats, forward/backward/lateral lunges
• Elliptical trainer, treadmill walking
• Standing knee flexion/extension
• Leg press (progressive loading)
• Aerobic conditioning - walking, cycling, swimming (once wound fully healed)

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PHASE V - RETURN TO ACTIVITY (Weeks 12+)

• Recreational walking, light hiking
• Swimming (front and back crawl)
• Recreational cycling
• Golf, ballroom dancing
• Driving (usually 6+ weeks, right knee longer)

• Vigorous walking/hiking
• Singles tennis
• Repetitive stair climbing
• Lifting >25 kg repetitively

• Running, jogging
• Contact sports
• Jumping sports
• High-impact aerobics

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KEY EVIDENCE SUMMARY

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IMPORTANT ROM TARGETS AT A GLANCE

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