LE Post-Op Flashcards
Rehab and response to surgery largely depends
- extent of tissue damage
- surgical technique/expectations
- patient factors
- current stage of healing
- tissue/structure characteristics
immediate post op red/yellow flags
- incision
- fever
- pain or symptom characteristics outside of surgical expectations
- DVT signs
DVT signs
Tenderness along venous system
Global LE swelling
Severe pain
Homan’s Sign (questionable metrics, but useful)
Maximal protective phase
0-6 weeks typically
Patient education
Ensure restrictions (WBing, lifting, etc)
Manage pain/swelling
Protect surgical structures Address non-direct tissues/structures
Maintain mobility/strength of non-op side
Minimize atrophy of surrounding tissues
Prevent infection/ pulmonary complications
Moderate protective phase
4-6 weeks
Less pain
Restore ROM
Scar mobility
Increase neuromuscular control
Strengthening? depends on surgery
minimal protective phases
6-12+ weeks
Minimal/no external protection likely
Strength
Function
Sports Specific
what position is muscle sutured and immobilized in?
shortened
muscle repair considerations
ROM within protected ranges can begin AFTER immobilization is removed
tendon repair considerations
ROM often initiated in max phase
what does muscle and tendon repair strengthening being with
low load and high reps
- concentric/isometric
what is contraindicated for 6-8 weeks following muscle and tendon repair
vigorous stretching and full contraction against resistance
general ligament repair procedure considerations
*Immobilization in safe position to reduce excessive tension of graft
*Early protective ROM is allowed typically *Progression highly dependent on specific ligament function
*May take 9-12 months for full healing of repair
Eval of post-op patient
- Obtain/review protocol *Subjective history – include post-op history and restrictions
*Full screen of joints above and below
*ROM assessed for involved joint within restrictions and tolerance
*Strength assessment of involved joints usually deferred
*Function/gait assessed within restrictions
*Incision assessment *Edema Assessment
*Soft tissue assessment
what does lumbar fusion use
hardware/implants and bone graft
why is lumbar fusion done
to prevent progression of degeneration stenosis, spondy, or dysfunctional mobility
bone growth stimulator for lumbar fusion
- surgeon dependent
- patient dependent (comorbidities, smoker, multi-level fusion)
lumbar fusion rehab- educate in positioning of comfort and decreased stress to structures
Side w/ pillows for alignments
Supine with pillow support to decrease lumbar stress
Avoid prone
lumbar fusion - restricted movements depending on stage of healing or overall task stress
Sitting/driving due to flexion stress - prolonged
Flexion exercises until healing occurs (especially segmental flexion stressors)**
Extension to neutral is typically appropriate
Ambulation within tolerance and goal to progress off AD and into walking routine
Lifting > 5 lbs for during first 1-2 phases**
phase 1 rehab lumbar fusion
- safe mobility
- core engagement
- muscle activation
- LE strengthening
- upright posture exercise
Phase 2 rehab lumbar fusion
- progress core to include UE/LE
- introduce CKC
- progress LE strengthening
- balance
- cardio
when is lumbar discectomy/laminectomy recommended
Ineffective conservative treatment
Rapid onset of myopathy, muscle wasting, weakness, or loss of bowel/bladder function
discectomy and laminectomy rehab
- overall comparable to fusion with more rapid progression
- phase 1 can be more advanced compared to fusion (pt and surgeon dependent)
- supine and SL positions appropriate
- cardio
what position is limited s/p supine and side lying positions appropriate
Prone (extension) limited with laminectomy during max protective (and possibly during moderate) phases and progressed slowly
rehab considerations post labral tear
- hip brace
- rehab can being POD #1-3 or some wait up to 2 weeks
- continuous ROM
- TD/Flat foot WB vs NWB
- pt ed
- do not ignore core, pelvic floor, ankle strengthening
- prone lying daily (use positioning to advantage)
hip brace post labral tear
limits ROM based on procedure
ex: 0 degrees ext, 25 ABD, 90 flex, 0 IR, 20-30 ER
typically wear 24 hrs, 2-6 weeks
what does phase transition in labral tear depend on
dc of brace or AD and as appropriate muscle activation/ strength
hip arthroscopic surgery - femoroplasty and acetabuloplasty
shaving bone
very painful
hip arthroscopic surgery - micro fracture
may increase WB restrictions and time
hip arthroscopic surgery - capsular plication/capsulorraphy
- avoid ext/ER in early phase
- avoid prone in early phase
- avoid aggressive/end range stretches
hip arthroscopic surgery - iliopsoas release
- limit hip flexion contraction
- consider positional stretching
hip arthroscopic surgery - glute med repair
- depends on thickness of tear
- very restricted ROM/ strengthening to avoid stress to healing contractile tissue
- can be up to 6-8 weeks of brace use/WB
femoral fracture rehab considerations
- early considerations on protecting fracture and promoting mobility
- WB dependent on characteristics (most fixation allow immediate WBAT**)
- progression based on protective phases (90 hip flex within 2-4 weeks)
femoral fracture complications
Non-union healing
Failure of hardware
Secondary complications from initial injury if traumatic
Greater trochanter: Gluteus medius
Lesser trochanter: iliopsoas
Subtrochanteric region: gluteus max
Persistent/high intensity pain in groin
Excessive Trendelenburg sign
Progressive leg length discrepancy*
micro fracture (knee)
Stimulate “marrow based repair response” and development of fibrocartilage
Osteochondral autograft/allograft transfer (OATs) (knee)
Bone to bone transfer, donor site from non-WB location
For focal lesions, non-TKA appropriate
Mosaicplasty – similar, using small osteochondral plugs from donor site vs. single piece of tissue (OAT)
Autologous chondrocyte implantation (ACI)
Harvested chondrocyte from patient, developed in lab, surgically implanted
Early positioning (ensuring proper contact of chondrocytes to surface and use of gravity)
Very long healing process (6-9 months)
Reserved for young populations typically following traumatic articular deficit
Early rehab OATs/ACI
- PROM only for up to 6 weeks (CPM)
- full knee ext PROM needed immediately
- locking brace full ext
- d/c after proper healing and quad control (6 wks)
which type of meniscus repair is gold standard
inside-out
meniscus repair
- ext lock knee brace
ROM restriction: restricted to 90 deg flexion for first 2 weeks (at least) with typical 10 deg increase each week until full.*
peripheral/red zone repair sometimes allows PWB immediately; FWB by 4 weeks
NWB/TTWB for central/root repairs common for 4-6 weeks. (possibly longer for meniscus transplants)*
meniscus repair squating progression
0-45 deg knee flex for first 4 weeks
0-60/70 deg knee flex for up to 8 weeks
Deep squatting, twisting and pivoting at 4-6 months
how long are hamstring curls avoided for meniscus repair
8 weeks
early rehab focus of meniscus repair
restoring full knee extension ROM
managing pain
promoting quad activation/resolving extension lag
meniscus repair possible complications
- saphenous nerve injury (medial)
- peroneal nerve injury (lateral)
- failed repair
- failed rehab (extensor lag, flexion contracture)
meniscectomy
- no immobilization
- WBAT
- ROM progress as tolerated
gold standard ACL reconstruction
- patella tendon graft
ACL immobilization
Only for early protection (versus meniscus repair)
Can be present from 1-6 weeks pending surgeon/procedure
Use with particularly unstable knee
ACL knee ROM
Progression based on surgeon preference and patient signs/symptom
Regardless – early full knee extension is a must! Literature suggests by 4 weeks (I say earlier)
90-110 deg knee flexion by weeks 4-6
ACL WB
Varies: WBAT immediately to some form of PWB
FWB without AD or brace can be achieved as early as 4 weeks if: good quad control, full knee extension, and no pain with WB.**
ACL Exercise precautions in max protective phase
- avoid ant translation of tib:
Open chain TKE (especially between 45 deg to full knee extension)
Closed chain quad strengthening between 60-90 deg flex
criteria for ACL rehab phase 2
Minimal pain/swelling
Full knee ext*
Proper quad activation (no extensor lag)*
At least 110 deg knee flex
Quad strength = 50-60% of uninvolved side
No evidence of excessive joint laxity
criteria for ACL rehab phase 3
Typically at weeks 10-12
No joint pain/effusion
75% quad function compared to uninvolved side
Functional Hop Test > 70%
Hamstring:Quad ratio > 65%
TAA - immobilization
Neutral ankle position with short cast/posterior
orthosis immediately post-op for 10-21 days
Then replaced with walking cast/controlled ankle
motion (CAM) boot
TAA WB
Varies
Ranges from NWB 3-6 wks to mild PWB to WBAT
within 2 weeks.
Regardless, typically achieve FWB in 6 weeks in
immobilizer
TAA rehab considerations in max protective
Gait/AD training
Transfer/mobility training
WB restriction education and training
Low isometrics of ankle musculature
AROM of toes
Ankle ROM – initiated within 2-6 weeks.
Initiate appropriate LE strengthening
ankle arthodesis
“gold standard” for
surgical management of this condition
Indicated for younger, post-traumatic arthritis of TC joint that has high functional demands and can
compensate through surrounding joints well.
- ankle fused on 0 DF, 5-10 ER
arthrodesis WB
non-WB for up to 6 weeks, begin PWB training when evidence of bony union
FWB in normal footwear common by weeks 12-16.
Custom shoe/orthotic typical
Lat ankle lig surgery WB
2-6 weeks NWB in cast followed by WBAT 2-4 weeks in CAM boot or orthosis
Recent evidence may suggest immediate PWB is helpful for recovery, but not currently most common
FWB without immobilization at about 6-12 week
lat ankle lig surgery Max protective stage
Similar to most ortho surgeries (pain/edema, education, etc)
Ankle PF and DF ROM as tolerated
Inversion/Eversion typically restricted to 10-15 deg arc***
lat ankle lig surgery mod/min
Full ankle ROM by 8 weeks Restore normal gait without AD or boot
Restore LE strength, balance, and proprioception
Traditional achilles tendon repair
Immobilized in 20 deg PF for 6 weeks
NWB during this time Progress to CAM boot and 0 deg DF in moderate phase Some suggestions this may increase DF ROM restrictions and weak PF
early mob and WB achilles tendon repair
Typically less than 2 weeks immobilization into
20 deg PF
Use of hinged CAM boot during this time to
allow WBAT, locked at appropriate ROM
Progress to 0 deg DF in orthosis or CAM boot
for additional 6 weeks
Achilles tendon repair DF ROM progression
Not > 10 deg DF by 8 weeks
Symmetrical DF by 12 weeks
achilles tendon repair progression to plyometric activity
◦ No earlier than 12 weeks and pending:
◦ Full DF ROM
◦ No pain with ambulation/WB
◦ 5 unilateral heel raises >/= to 90% of contralateral height
