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Advanced Musculoskeletal > LE Post-Op > Flashcards

LE Post-Op Flashcards

1
Q

Rehab and response to surgery largely depends

A
  • extent of tissue damage
  • surgical technique/expectations
  • patient factors
  • current stage of healing
  • tissue/structure characteristics
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2
Q

immediate post op red/yellow flags

A
  • incision
  • fever
  • pain or symptom characteristics outside of surgical expectations
  • DVT signs
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3
Q

DVT signs

A

 Tenderness along venous system
 Global LE swelling
 Severe pain
 Homan’s Sign (questionable metrics, but useful)

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4
Q

Maximal protective phase

A

 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

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5
Q

Moderate protective phase

A

 4-6 weeks
 Less pain
 Restore ROM
 Scar mobility
 Increase neuromuscular control
 Strengthening? depends on surgery

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6
Q

minimal protective phases

A

 6-12+ weeks
 Minimal/no external protection likely
 Strength
 Function
 Sports Specific

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7
Q

what position is muscle sutured and immobilized in?

A

shortened

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8
Q

muscle repair considerations

A

ROM within protected ranges can begin AFTER immobilization is removed

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9
Q

tendon repair considerations

A

ROM often initiated in max phase

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10
Q

what does muscle and tendon repair strengthening being with

A

low load and high reps
- concentric/isometric

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11
Q

what is contraindicated for 6-8 weeks following muscle and tendon repair

A

vigorous stretching and full contraction against resistance

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12
Q

general ligament repair procedure considerations

A

*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

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13
Q

Eval of post-op patient

A
  • 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
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14
Q

what does lumbar fusion use

A

hardware/implants and bone graft

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15
Q

why is lumbar fusion done

A

to prevent progression of degeneration stenosis, spondy, or dysfunctional mobility

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16
Q

bone growth stimulator for lumbar fusion

A
  • surgeon dependent
  • patient dependent (comorbidities, smoker, multi-level fusion)
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17
Q

lumbar fusion rehab- educate in positioning of comfort and decreased stress to structures

A

 Side w/ pillows for alignments
 Supine with pillow support to decrease lumbar stress
 Avoid prone

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18
Q

lumbar fusion - restricted movements depending on stage of healing or overall task stress

A

 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**

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19
Q

phase 1 rehab lumbar fusion

A
  • safe mobility
  • core engagement
  • muscle activation
  • LE strengthening
  • upright posture exercise
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20
Q

Phase 2 rehab lumbar fusion

A
  • progress core to include UE/LE
  • introduce CKC
  • progress LE strengthening
  • balance
  • cardio
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21
Q

when is lumbar discectomy/laminectomy recommended

A

 Ineffective conservative treatment
 Rapid onset of myopathy, muscle wasting, weakness, or loss of bowel/bladder function

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22
Q

discectomy and laminectomy rehab

A
  • 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
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23
Q

what position is limited s/p supine and side lying positions appropriate

A

 Prone (extension) limited with laminectomy during max protective (and possibly during moderate) phases and progressed slowly

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24
Q

rehab considerations post labral tear

A
  • 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)
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25
Q

hip brace post labral tear

A

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

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26
Q

what does phase transition in labral tear depend on

A

dc of brace or AD and as appropriate muscle activation/ strength

27
Q

hip arthroscopic surgery - femoroplasty and acetabuloplasty

A

shaving bone
very painful

28
Q

hip arthroscopic surgery - micro fracture

A

may increase WB restrictions and time

29
Q

hip arthroscopic surgery - capsular plication/capsulorraphy

A
  • avoid ext/ER in early phase
  • avoid prone in early phase
  • avoid aggressive/end range stretches
30
Q

hip arthroscopic surgery - iliopsoas release

A
  • limit hip flexion contraction
  • consider positional stretching
31
Q

hip arthroscopic surgery - glute med repair

A
  • 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
32
Q

femoral fracture rehab considerations

A
  • 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)
33
Q

femoral fracture complications

A

 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*

34
Q

micro fracture (knee)

A

Stimulate “marrow based repair response” and development of fibrocartilage

35
Q

Osteochondral autograft/allograft transfer (OATs) (knee)

A

 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)

36
Q

Autologous chondrocyte implantation (ACI)

A

 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

37
Q

Early rehab OATs/ACI

A
  • 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)
38
Q

which type of meniscus repair is gold standard

A

inside-out

39
Q

meniscus repair

A
  • 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)    *
40
Q

meniscus repair squating progression

A

 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

41
Q

how long are hamstring curls avoided for meniscus repair

A

8 weeks

42
Q

early rehab focus of meniscus repair

A

 restoring full knee extension ROM
 managing pain
 promoting quad activation/resolving extension lag

43
Q

meniscus repair possible complications

A
  • saphenous nerve injury (medial)
  • peroneal nerve injury (lateral)
  • failed repair
  • failed rehab (extensor lag, flexion contracture)
44
Q

meniscectomy

A
  • no immobilization
  • WBAT
  • ROM progress as tolerated
45
Q

gold standard ACL reconstruction

A
  • patella tendon graft
46
Q

ACL immobilization

A

 Only for early protection (versus meniscus repair)
 Can be present from 1-6 weeks pending surgeon/procedure
 Use with particularly unstable knee

47
Q

ACL knee ROM

A

 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

48
Q

ACL WB

A

 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.**

49
Q

ACL Exercise precautions in max protective phase

A
  • 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
50
Q

criteria for ACL rehab phase 2

A

 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

51
Q

criteria for ACL rehab phase 3

A

 Typically at weeks 10-12
 No joint pain/effusion
 75% quad function compared to uninvolved side
 Functional Hop Test > 70%
 Hamstring:Quad ratio > 65%

52
Q

TAA - immobilization

A

 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

53
Q

TAA WB

A

 Varies
 Ranges from NWB 3-6 wks to mild PWB to WBAT
within 2 weeks.
 Regardless, typically achieve FWB in 6 weeks in
immobilizer

54
Q

TAA rehab considerations in max protective

A

 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

55
Q

ankle arthodesis

A

“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

56
Q

arthrodesis WB

A

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

57
Q

Lat ankle lig surgery WB

A

 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

58
Q

lat ankle lig surgery Max protective stage

A

 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***

59
Q

lat ankle lig surgery mod/min

A

 Full ankle ROM by 8 weeks  Restore normal gait without AD or boot
 Restore LE strength, balance, and proprioception

60
Q

Traditional achilles tendon repair

A

 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

61
Q

early mob and WB achilles tendon repair

A

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

62
Q

Achilles tendon repair DF ROM progression

A

 Not > 10 deg DF by 8 weeks
 Symmetrical DF by 12 weeks

63
Q

achilles tendon repair progression to plyometric activity

A

◦ No earlier than 12 weeks and pending:
◦ Full DF ROM
◦ No pain with ambulation/WB
◦ 5 unilateral heel raises >/= to 90% of contralateral height

64
Q
A

Advanced Musculoskeletal (21 decks)

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