Orthopedic Surgical Procedures and Conditions

Question 1

Total shoulder arthoplasty

–Surgical Considerations

Answer 1

• Often performed when joiny components have become arthritic, though may also be done secondary to fracture or rotator cuff athropathy.
• Total shoulder athroplasty replaces both the glenoid and humeral components, while a shoulder hemiarthoplasty replaces only one of those components

Question 2

Reverse total shoulder

Answer 2

-a reverse total shoulder is perfomed by reversing the concave-convex relationship of the prosthetic components and is used as the surgery of choice when the patient has a dysfunctional rotator cuff.

Question 3

Total Shoulder arthoplasty

–rehab consideration

Answer 3

• the patient will be immobilized in a sling for several weeks or longer if there was a repair perfomed on muscles/tendon
• protocols vary widely after these surgeries, but there likely will be some movement precautions for a short period of time.
• for example, the patient often has to avoid extension and external rotation movements to help protect the healing subscapularis muscle and anterior portion of the capsule. Resisted IR is also avoided for some time for this same reason
• there may also be restrictions on WB through the arm and limitations on lifting or carrying weight

Question 4

Subacromial Decompression surgical consideration

Answer 4

• surgery is performed when cases of shoulder impingement have not responded to conservative treatment. the approach can be open, a mini-open or athroscopic.
• The procedure could involve an acromioplasty, bursectomy, removal of teh distal clavicle and release of the coracoacromial ligament

Question 5

Subacromial Decompression

– Rehab considerations

Answer 5

• typically patients experience a rapid recovery from this surgery. a sling will only be used for 1-2 weeks since no repair has been performed
• early rehab focuses on pain control and gentle ROM, with strength training occuring later in rehab.
• if a deltoid repair was performed, passive extension is avoided initially to prevent stress on the repair site
• tx should focus on interventions to reduce the occurence of impingement
• a full recovery is typically expected

Question 6

Rotator Cuff repair

–surgical considerations

Answer 6

• rotator cuff tears are graded according to depth and according to width
• small partial-thickness tears may only require debridement; all others likely require a repair to be performed, in which the tear is reapproximated and fixated using sutures anchors tacks or staples. as with a subacromial decompression the surgery is generally performed arthroscopically though an open mini-open approach may be necessary

Question 7

Rotator Cuff repair

-rehab considerations

Answer 7

• the patient will be immobilized in a sling for several weeks and the sling may have an abduction pillow attached to it.
• Sling use is generally at the discretion of the surgeon and often depends on the extent of the tear/repair
• Rehab protocols vary, but therapy usually consists of passive and AROM initially, with strengthening occurring later in teh course of therapy
• precautions generally include no AROM, lifting, or WB through the arm for several weeks
• depending on which muscle is repaired, there may be precautions set on ROM for rotation as well
• if a deltoid repair was performed, passive exetnsion is avoided initially to prevent stress on the repair site

Question 8

Shoulder Stabilization Surgeries

-surgical consideration

Answer 8

• performed in the presence of chronic shoulder instability. the procedure involves tightening of the joint capsule by cutting the capsule and overlapping the ends to reduce capsular redundancy.
  there is also an electrothermally assissted capsular shift procedure in which thermal energy is used to shrink and tighten the capsular tissue. the portion of the capsule that is tightened is dependent upon the direction of the instability
  -since anterior instability is the most common form of shoulder instability, the anterior capsule is the portion that is most often tightened.
  -in addition to the capsular shift procedure, labral repairs may also be performed since labral tears often accompany dislocation injuries

Question 9

Bankart lesion

Answer 9

• involves a repair of the anterior labrum

Question 10

SLAP repair

Answer 10

• repair of teh superior labrum

Question 11

Shoulder stabilization Surgeries

– rehab considerations

Answer 11

• type of immobilization used and the precautions will depend on the portion of the capsule that was affected.
  -if the anterior capsule was affected, then the patient will typically utilize a normal sling.
  -they should avoid positions of ER, extension, and horizontal adduction.
  they should also avoid resisted IR if the subscapularis muscle was detached during the surgery.
  -if the posterior capsule was affected, the patient would be immobilized in the “hand shake” position with the shoulder in neutral rotation. the patient should avoid positions of IR, flexion and horizontal adduction. AROM can begin soon after the surgery. therapists should not wait for full ROM before beginning strengthening exercises and should not bee overly aggressive in getting full motion early.
  -if a slap repair has been performed, the patient should avoid contracting or stretching the biceps since it is attached to the superior labrum

Question 12

Hip ORIF

-surgical consideration

Answer 12

• proximal hip fractures commonly occur in the femoral neck or in the intertrochanteric region
• femoral neck fractures are intrascapular and may lead to disruption of teh 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 the blood supply. though nonunion is less of an issues, implany failure is more of a problem with these fractures since the fixation needed is greater
• fractures can also occur in the subtrochanteric region, which is the region distal to the trochanters
• there are several methods of fixation for hip fractures, and the method used depends on fracture location, amount of displacemt and the patient’s activity level
• fixation usually occurs with the use of plates and screws or an intramedullary nail
• for older pt with poor healing capacity, THA is often considered
• the surgery is always an open procedure. depending on the approach, the tensor fascia latae, gluteus medius and vastus lateralis may be affected
• if the fracture site is intracapsular, a capsulotomy will be performed

Question 13

Hip ORIF

– rehab consideration

Answer 13

• new advances in this surgery have allowed for early WB, though WB restrictions will be based on age, the location of the fracture and the bone quality. Early rehab consists of ambulation and ROM.
• isotonics strengthening is usually postponed until the muscles have been given a chance to heal.
• the muscles affected depend not only on the surgical approach, but also on the site of the fracture.
• for example, fractures of teh greater trochanter will affect the gluteus medius while fractures of the lesser trochanter will affect the iliopsoas. therapist should be aware of signs of fixation failure, such as persistent thigh or groin pain, a leg length discrepancy that was not present initially positioning the limb in ER, or a Trandelenburg sign that does not improve with strengthening

Question 14

Surgeries to fix Articular Cartilage Defects

Answer 14

There are several different options for fixing focal cartilage defects. the microfracture procedure uses an awl to penetrate subchondral bone, which causes an ingrowth of fibrocartilage

• Osteochondral autograft transplantation is a procedure in which cartilage is harvested from several non-WB surfaces to form a plug that can fill the chondral defect
• autologous chondrocyte implantation is a procedure in which healthy catilage is harvested and cultured so it will grow, the later impanted into the cartilage defect

Question 15

Surgeries to fix Articular cartilage defects

- rehab consideration

Answer 15

• there will likely be WB restrictions, though this is dependent upon teh size and location of the lesion.
• adherence to WB restrictions is critical to allow healing to occur.
• teh patient wil often be in a brace that is initially locked into extension.
• ROM progression will also vary depending on the size and location of teh lesion. in general, larger lesions require a slower overall progression

Question 16

Anterior Cruciate Ligament reconstruction

-surgical consideration

Answer 16

• surgery is performed on patients with an ACL tear that is causing pain and/or instability. teh surgery is generally performed arthroscopically. use of an autograft is preferred over allograft.
• abone patellar tendon-bone graft is considered teh gold standard
• because it uses bone-to-bone healing, it is considered a stronger graft with good fixation. use of teh gracilis and/or semitendinosus is also common, however, the fixation is not as strong since it uses tendon-to bone healing

Question 17

ACL reconstruction

-Rehab considerations

Answer 17

• generally some period of immobilization in a hinged brace in addition to WB restrictions. the brace usually is unlocked once the patient can demonstrate good quad control
• ROM interventions should place an emphasis on achieving full knee extension early in the rehab process.
• strengthening can occur soon after surgery and typically include isometric quads, hamstring strengthening and closed-chain exercises
• open-chain exercises between 0-45 degrees of flexion should be avoided since they place excess stress on the graft site.

Question 18

PCL reconstruction

-surgical considerations

Answer 18

• injuries to the PCL are much less common than ACL injuries. if the PCL injury occurs in isolation, surgery may not be needed.
• surgery is indicated if pain and/or instability do not improve with therapy. options for grafts are similar to those for ACL surgery

Question 19

PCL reconstruction

-rehab considerations

Answer 19

• in general, teh rehab protocol is the same as with ACL surgery.
• however, teh progression with WB and with exercises tends to be more gradual
• the therapist should choose exercises that will limit posterior shear forces within the knee.
• repetitive knee flexion should also be avoided

Question 20

Surgeries for meniscal injuries

– surgical considerations

Answer 20

• surgery for a meniscus tear is generally performed arthoscopically.
• meniscus tears can be dealt with surgically in two ways. the first option is a partial menisectomy in which the torn piece of meniscus is removed
• this option is usually chosen for older individuals or when teh tear occurs in teh inner third of teh meniscus where teh healing capacity i spoor
• the other sugical option i sto perform a repair of teh meniscus in which the tear is sutured back together. this option is more likely to be chosen in younger patients or when the tear is in the outer third of teh meniscus

Question 21

Surgeries for meniscal injuries

- rehab considerations

Answer 21

• rehab protocol will depend on whether or not the meniscus was repaired. Following a meniscus repair, there will likely be a period of restricted WB in addition to bracing.
• there will also likley be limitations placed on teh progression of ROM, specifically with flexion
• following a partial menisectomy, the patient is full WB without the use of brace. there are no rehab restrictions and recovery time is significantly quicker

Question 22

Lateral Ankle Reconstruction

-surgeries consideration

Answer 22

• repair of the lateral ankle ligaments is commonly performed secondary to a complete tear of teh anterior talofibular ligament or calcaneofibular ligament or secondary to chronic ankle instability. there are two methhods for reconstructing the ankle, both of which use an open approach.
• first method involves actual repair of the torn ligaments in which they are sutured back together. the second method involves the harvesting of an autograft to replace teh torn ligaments
• this second option is usually performed when the original ligaments canot be repaired due to deterioration
• teh surgery may also include arthoscopy or subchondral drilling since a high percentage of unstable ankles have chondral lesions within the joint

Question 23

Lateral ankle Reconstruction

- rehab considerations

Answer 23

• the patient will usually be in a protective cast for short period of time, then they are placed in a walking cast or boot for several weeks, followed by a brace. Initially the patient is non-WB while in the protective cast, which is progressed to partial WB and full WB once in teh walking boot.
• therapy does not usually begin immediately after surgery.
• early rehab focuses on increasing the patient’s ROM while still protecting the repaired tissues.
• Caution should be taken when ranging the ankle into inversion since this will stress the repaired tissues.
• bracing may be required long term if the patient plans to return to sports or higher level activities

Question 24

Achilles tendon repair

-surgical considerations

Answer 24

• this surgery is performed on active patients with an achilles tendon tear. when the repair is performed within days of teh injury, it is generally done arthroscopicqally.
• the torn portion of teh tendon is sutured back together.
• However, when the repair is delayed after the injury, the surgery may need to be performed as an open procedure.
• additionally, augmentation with use of a graft may be needed for the repair instead of suturing together the original tendon

Question 25

Achilles Tendon Repair

- Rehab Considerations

Answer 25

• Pt will likely be casted with the ankle in slight PF initially. additionally, the patient may be non-WB for teh first several weeks. eventually, the patient is transitioned to a cast or boot that places the ankle in neutral and they are allowed to be partial WB.
• however, in the past few decades, there has been a push for more aggressive rehab following this surgery,in which the ankle is casted in neutral and partial WB is allowed much sooner in the recovery process.
• Researchers have found that this leads to less restricted ROM long term. during the healing process, the therapist should take caution with exercises that stretch teh Achilles tendon or require active PF until the tendon is well healed

Question 26

Laminectomy

-surgical considerations

Answer 26

• usually performed in the presence of a disk protrusion or spinal stenosis. A complete laminectomy involves the removal of the entire lamina, the spinous process, and the associated ligamentum flavum. a partial lamienctomy involves the removal of only one lamina.
• in cases where a complete laminectomy is perfomed, the vertebral segment will be much less stable than when a partial laminectomy is performed. Both cervical and lumbar laminectomies are generally performed usig a posterior approach

Question 27

laminectomy

- rehab considerations

Answer 27

• there will likely be restrictions on how much weight can be lifted following surgery
• the surgeon may also place restrictions on active motions, especially extension. teh physical therapist should emphasize the need for proper body mechanics and posture with the patient

Question 28

spinal fusion

- surgical considerations

Answer 28

• spinal fusion is indicated in teh presence of axial pain with unstable spinal segments, advanced arthritis, or uncontrolled peripheral pain. Bone is ahrvested from the patient’s body and used to help fuse two vertebrae together. generally the surgeon will use instrumentation to immobilize at one spinal segment, it inherently leads to hypermobility at adjacent segments, which can hasten the onset of degeneration

Question 29

spinal fusion

-surgical consideration

Answer 29

• is indicated in the presence of axial pain with unstable spinal segments, advanced arthritis, or uncontrolled perpheral pain. bone is harvested from the patient’s body and used to help fuse two vertebrae together. generally the surgeon will use instrumentation to immobilize the segments while a bony callus forms between the segments
• cevical fusion typically uses an anterior approach while lumbar fusion typically uses a posterior approach
• because a fusion creates immobility at one spinal segment, it inherently leads to hypermobility at adjacent segments, which can hasten the onset of degeneration

Question 30

spinal fusion

- rehab consideration

Answer 30

• surgeon will likely place restriction on how much can be lifted following surgery.
• teh surgeon may also place restrictions on atcive motion, such as bending or twisting motions.
• early therapy occurs post-operatively in the hospital and involves teaching bed mobility and transfers with the patient to help them become more mobile without compromising the established precautions. bracing may be used to help patients comply with the movement precautions. bracing is more likely to be used if teh surgeon does not use instrumentation to stabilize the segments. formal outpatients therapy does not usually occur until approx 6 weels after the surgery. if instrumentation is used, therapy will usually begin sooner and can be progressed more aggressively. emphasis should be placed on proper mechanics and posture, as well as core stabilization exercises