Orthopedic Surgical Procedures Flashcards
1
Q
Laminectomy
A
surgical considerations
- usually performed in the presence of a disk protrusion or spinal stenosis
- full: removal of entire lamina, spnous process, and associated ligamentum flavum
- partial: removal of only one lamina
- vertebral segment is much less stable after a full versus a partial
- usually performed using a posterior approach
rehab considerations
- restrictions on how much weight can be lifted following surgery
- restrictions on active motions (extension)
- emphasize need for proper body mechanics and posture with the patient
2
Q
Spinal Fusion
A
surgical considerations
- indicated in the presence of axial pain with unstable spinal segments, advanced arthritis, or uncontrolled peripheral pain
- bone is harvested (from iliac crest) and used to help fuse vertebrea together- sometimes will uses instrumentation to immobilize segments
- cervical fusion typically uses an anterior approach, lumbar fusion typically uses a posterior approach
- leads to hypermobility at adjacent segments, which can hasten onset of degeneration
rehab considerations
- lifting, bending, twisting restrictions
- early therapy focuses on bed mobility and transfers
- bracing is more likely used if instrumentation was not used
- outpatient does not occur until 6 weeks out unless instrumentation was used, then it can begin sooner and be progressed sooner
- focus should be on proper body mechanics and posture, as well as core stabilization exercises
3
Q
Total Shoulder Arthroplasty
A
surgical considerations
- often performed when joint components have become arthritic, may be done secondary to fracture or RC athropathy
- total shoulder arthroplasty replaces both glenoid and humeral components
- shoulder hemiarthroplasty replaces one or the other
- reverse total shoulder reverses the concave-convex relationship and is used as the surgery of choice when patient has a dysfunctional rotator cuff
- anterior approach in which the subscap muscle is detached for easier access to the joint
rehab considerations
- will be immobilized in a sling for several weeks or longer if there was a repair performed on muscles
- movement precautions for a short period
- avoid extension and external rotation movements
- resisted internal rotation is also avoided for some time
- restrictions on weightbearing through arm, limitations on lifting or carrying
4
Q
Subacromial Decompression
A
surgical consideration
- when cases of shoulder impingement have not responded to conservative treatment
- can be open (deltoid is detached), mini-open (deltoid is only split), arthroscopic
- can involve acromioplasty, bursectomy, removal of the distal clavicale, and release of the coracoacromial ligament
rehab considerations
- experience a rapid recovery
- sling is only used 1-2 weeks
- early rehab focuses on pain control and gentle range of motion, with strength training occuring later
- if deltoid repair was performed, passive extension is avoided
- treatment should focus on reducing the occurrence of impingement
- full recovery is typically expected
5
Q
rotator cuff repair
A
surgical consideration
- graded according to depth and width
- small partial thickness may only require debridement
- all others require a repair where the tear is reapproximated and fixated using sutures
rehab considerations
- immibilized in a sling for several weeks
- therapy consists of passive and active-assisted ROM initially with strengthening happening later
- precautions include no AROM, lifting, weightbearing through arm
- if deltoid was repaired, no passive extension
6
Q
Shoulder Stabilization surgery
A
surgical considerations
- performed in presence of chronic shoulder instability
- involves tightening the joint capsule
- can also do an electrothermally assisted capsular shift procedure in which thermal energy is used to shrink and tighten the capsular tissue
- anterior instability is the most common form of shoulder instability, the anterior capsule is the portion most often tightened
- labral repairs may also be performed since labral tears often accompany dislocation injuries
- bankart repair involves a repair of the anterior labrum
- SLAP repair involves a repair to the superior labrum
- if the procedure is open, then the subscap muscle may need to be detached
rehab considerations
- if anterior capsule was affected, then the patient will use a normal sling
- they should avoid positions of ER, extension, and horizontal abduction
- they should avoid resisted internal rotation if the subscap was detached during surgery
- if the posterior capsule was affected, the patient would be immobilized in the hand shake position with shoulder in neutral rotation
- this patient should avoid IR, flexion, and horizontal adduction
- AROM can begin soon after surgery
- therapists should not wait for full ROM before beginning strengthening exercises and should not be overly aggressive in getting full motion early
- if a SLAP repair has been performed, the patient should avoid contracting or stretching biceps since it attaches to superior labrum
7
Q
Hip ORIF
A
surgical considerations
- femoral neck fractures are intracapsular and may lead to disruption of the blood supply to the femoral head
- because of this, nonunion and osteonecrosis are more common with these fractures
- Intertrochanteric hip fractures are extracapsular and therefore do not affect blood supply
- nonunion is less of an issue, but implant failure is more of a problem with these fractures since the fixation need is greater
- fractures can also be in the subtrochanteric region, which is the region distal to the trochanters
- for older patients with poor healing capacity, total hip is often considered
- the surgery is always open
- TFL, glute med, and vastus lateralis may be affected
- if fracture is intracapsular, a capsulotomy will be performed
rehab considerations
- early weight bearing, though weight bearing restrictions are based on age, location of fracture, and bone quality
- early rehab consists of ambulation and range of motion, isotonic strengthening is postponed until muscles heal
- be aware of signs of fixation failure such as persistent this or groin pain, a leg length discrepancy that was not present initially, positioning the limb in ER or a tendelenburg sign that does not improve with strengthening
8
Q
Surgeries to fix articular cartilage defects
A
surgical considerations
- microfracture procedure uses an awl to penetrate subchondrol bone, which causes an ingrowth of fibrocartilage
- osteochondral autograft transplantation is a procedure in which cartilage is harvested from several non-weight bearing surfaces to form a plug that can fill the chondral defect
- autologous chondrocyte implantation is a procedure in which healthy cartilage is harvested and cultured so it will grow and then later implanted into the cartilage defect
rehab considerations
- weight bearing restrictions
- adherence to weight bearing restrictions is critical to allow healing to occur
- will often be in a brace that is initially locked in extension
- ROM progression will also vary depending on the size and location
- larger lesions will require a slower overall progression
9
Q
ACL reconstruction
A
surgical consideration
- when ACL tear is causing pain or instability
- use of autograft is preferred over allograft
- a bone patellar tendon bone graft is considered to be gold standard; it uses bone to bone healing so it is considered to be a stronger graft with good fixation
- use of gracilis or semitendinosus is also common, however, the fixation is not as strong since it is tendon to bone healing
rehab considerations
- some period of immobilization in hinged brace (locked in extension), in addition to weightbearing restrictions
- brace is unlocked once patient can show good quad control
- ROM should take place on emphasis of achieving full knee extension
- strengthening should occur soon after surgery and should include isometric quad strengthening, hamstring strengthening, and close-chained exercises
- open chain exercises between 0-45 of flexion should be avoided
- bone patellar tendon bone graft may cause anterior knee pain and should be cautions with quad strengthening
- hamstring graft should be cautious with flexion exercises
- as tendon transforms into ligament, it gets weaker before it gets stronger at 6-8 weeks post surgery
- graft maturation has should to be around 100% around 12-16 months post op, most protocols allow for return to sport at 6 months
- return to sports must satisfy these: no pain or effusion, full range of motion, no instability, quad strength that is 85-90% of opposite leg, hamstring that is 95-100% of opposite leg, and functional testing that is 85-90% of opposite leg
10
Q
PCL reconstructin
A
surgical considerations
- if it occurs in isolation, surgery may not be needed
- surgery is indicated if pain and instability do not improve with therapy
rehab considerations
- same as ACL
- progressing with weight bearing and exercises are more gradual
- choose exercises that will limit posterior shear forces within the knee
- repetitive knee flexion should be avoided
11
Q
Meniscus injuries
A
surgical considerations
- partial menisectomy: torn piece is removed
- this is usually chosen for older adults or when the tear occurs on the inner two thirds of the meniscus where healing is poor
- repair the meniscus
- this is for younger patients or when the tear is in the outer two thirds of the meniscus
rehab considerations
- restricted weight bearing in addition to bracing
- limitations placed on progression of ROM, specifically flexion
- partial: full weight bearing without a brace
- no rehab restrictions and recovery time is signficantly quicker
12
Q
lateral ankle reconstruction
A
surgical considerations
- commonly performed secondary to complete tear of the anterior talofibular lig or calcaneofibular lig or secondary to chronic ankle instability
- first method involves actual repair of torn ligament
- second method involves harvesting autograft (peroneus brevis) to replace torn ligament
- second option is for when ligaments cannot be repaired
- subchondral drilling is sometimes included since high percentage of unstable ankles have chondral lesions within the joint
rehab considerations
- protective case for short period of time, then walking cast or book for several weeks, then brace
- non weight bearing to partial weight bearing and full weight bearing once in boot
- therapy does not begin immediately
- early rehab focuses on increasing the patient’s range of motion while still protecting repaired tissues
- caution should be taken with inversion
- bracing is used long term if return to sports
13
Q
Achilles tendon repair
A
surgical considerations
- performed on active patients with achilles tear
- if done within days of tear, performed arthroscopically
- if not done within days, may need to be repaired with open procedure
- uses graft (peroneus brevis, flexor hallicus longus, plantars)
rehab considerations
- will be casted with ankle slightly in plantar flexion
- non weight bearing for several weeks
- transitioned to boot placed in neutral with partial weight bearing
- therapist should take caution with exercises that stretch the achilles tendon or require active plantar flexion until the tendon is well healed
