Knee Surgery & Rehab Flashcards
What are the indications for surgery for knee fractures?
- Critical size defect of shaft of tibia 12 +/- 1mm, 50% cortex
- Infection/open injury
- Complex case (older, other pathology etc)
- Need to reconstruct the joint
How is a spiral fracture fixed surgically?
Intramedullary nailing - rod goes along the shaft of the bone & is nailed in place
What are the 3 types of extra articular distal femur fractures (type A)?
Simple
Metaphyseal wedge
Metaphyseal complex (comminution)
What is considered for a extra articular distal femur simple fracture & what are the surgical options?
- Apophyseal or metaphyseal
- Oblique or spiral
- Sx: traction, external fixation or plate & screws
What are the surgical options for metaphyseal articular wedge & comminution fractures?
Traction
External fixation
Plate & screws
What are the 3 types of partial articular distal femur fractures (type B)?
Lateral sagittal
Medial sagittal
Frontal
What occurs during medial and lateral sagittal fractures and what are the surgical options?
- Simple
- Through notch/condylar load bearing surface
- Rx: Plate & screws, external fixation
What is the aim for partial articular distal femur fractures?
- Anatomical restoration of the articular surface
- Early active mobilisation of the joint
What are the 3 types of complete articular distal femur fractures (type C)?
Simple
Metaphyseal comminution
Multifragmentary
What occurs during a simple complete articular fracture?
No part of the articular surface is in continuity with the diaphysis
What occurs during a metaphyseal complete articular fracture?
No part of the articular surface is in continuity with the diaphysis
Comminution of metaphysis
What occurs during a multifragmentary complete articular fracture?
No part of the articular surface is in continuity with the diaphysis
Comminution of metaphysis
Comminution of articular surface
What is the phase 1 principle for knee fracture rehabilitation?
Protect & maintain
How is the knee maintained?
- Restrictions on joint ROM
- Restrictions on muscle contraction/weight bearing
- Management of oedema (compression, elevation)
- Consider other joints
- Educate patient
What is the mechanism of tibial plateau fractures?
- Direct fall (20%)
- Car vs pedestrian (50%)
- Axial compression & rotation force (30%)
What types of tibial plateau fractures are associated with axial compression & rotation force?
- Lateral plateau (abduction force)
- Medial plateau (adduction)
- Anterior (extended knee)
- Posterior (flexed knee)
What are the indications for surgery for tibial plateau fractures?
- Type of fracture
- Age of patient (younger = less likely)
- Degree of displacement/articular surface
- Compromised knee stability
What are the types of proximal tibial fractures?
Extra-articular:
- Avulsion
- Metaphyseal simple
- Metaphyseal multifragmentary
Partial articular:
- Pure split
- Pure depression
- Split-depression
Complete articular:
- Simple, metaphyseal simple
- Simple metaphyseal multifragmentary
- Multifragmentary
What is the mechanism of patella fracture?
- Direct trauma/fall on knee
- Big pull of quad muscles
- Displaced or non-displaced
What are the indications for surgery for patella fractures?
- Displacement >3-4mm
- Loss of active knee extension
What is the rehabilitation for patella fractures post surgery?
Protect - Weight bear as tolerated (in a splint) Maintain - ROM - Quads/hamstrings (wasting is rapid)
What does patella fracture surgery involve?
Reduction with K-wires & tension band
What needs to be considered during patella rehabilitation?
- Preoperative history/impairments
- Surgical procedure/tecnhique
- Surgeon’s assessment of the tissue status
What are the common restrictions associated with patella rehabilitation?
- Active/passive ROM
- ROM limits
- Weight bearing status
- OA, pre-existing problems
- Tendinopathy, bursitis, quads strength
What is another name for a total knee replacement (TKR)
Total knee arthroplasty (TKA)
What are the main reasons for TKR (in order)?
- OA
- Rheumatoid arthritis
- Other inflammatory arthritis
- Osteonecrosis
- Other
What are the indications for TKR?
- Pain
- Loss of function
- Other treatments no longer sufficient
What is the relationship between age and TKR?
More likely to need another TKR sooner if under 55 years old (more likely to last longer with increased age)
What are the contraindications for TKR?
- Active infection
- Significant genu recurvatum (hyper extension)
- Excessive obesity
- High impact sports/occupation
- Arterial insufficiency
- Neuropathic joint
- Mental illness
What structures are cut in a TKR?
- Skin (longitudinal incision)
- Joint (quads tendon to tib tuberosity)
- Patella subluxed laterally
- Quads & hamstrings left intact
- ACL, tibial plateau
What are the complications associated with TKR?
- DVT
- Fat embolism
- Poor wound healing
- Infection
- Fractures
- Neuro problems
- Vascular injuries
- Arthrofibrosis
- Disruption of extensor mechanism
What exercises are allowed ‘as tolerated’ post TKR?
- ROM 0-90 deg
- Static/inner range quads
- FWB (WBAT)
What are the precautions for exercise post TKR?
- DVT
- Pain
- Bleeding
- Quads activation
What is the pathology of ACL injury?
- Rupture
- Avulsion
What are the indications for surgery for ACL?
- Competitive sports
- Functional deficits
- Other injuries
What are the pre-op goals for ACL?
- Full extension
- Able to do SLR without lag (good quads)
- Minimal to no swelling
What are the issues with BPTB graft compared to hamstring autograft for ACL recon?
BPTB:
- Patella pain
- VMO wasting
- Kneeling pain
Hamstring:
- Hamstring donor site
- Loss of ACL protection
What are the stages of maturation of the ACL graft post surgery?
- Necrosis (1-2 weeks)
- Revascularisation (6-8 weeks)
- Cellular proliferation
- Collagen formation, remodelling, maturation (1-2 years)
What are the ACLR treatment protocols for weeks 1-4?
- Protect healing graft
- Decrease swelling & inflammation
- Attain full extension
- Increase quads strength
What are the ACLR walking aid guidelines?
- Brace for 1-4 days until SLR
- Crutches 1-7 days until confident
