Orthopedic Surgical Procedures and Considerations

Question 1

Laminectomy

Answer 1

Usually performed due to disk protrusion or spinal stenosis.
Can be a partial or complete laminectomy. Complete involves removal of lamina, spinous process, and associated ligamentum flavum. Partial involves removal of only one lamina.
Lifting restrictions and restrictions on AROM, especially extension.
PT focuses on proper body mechanics and posture.

Question 2

Spinal fusion

Answer 2

Indicated with axial pain with unstable spinal segments, advanced arthritis, or uncontrolled peripheral pain.
Bone harvested, often from iliac crest, and used to fuse two vertebrae together. May immobilize with instrumentation.
Lifting restrictions and AROM restrictions, including bending or twisting motions.
Early therapy includes bed mobility and transfers following precautions.
Outpatient therapy about 6 weeks after surgery, focusing on body mechanics and posture and core stabilization.

Question 3

Total shoulder arthroplasty

Answer 3

Often due to arthritis, fracture, or RTC arthropathy.
Total shoulder replaces glenoid and humeral head while hemiarthroplasty only replaces one of these. Reverse total shoulder reverses the concave-convex relationship and is used when there is RTC dysfunction.
Pt will be immobilized in a sling for several weeks.
Likely movement precautions for 6-8 weeks, restrictions on weight bearing and lifting.

Question 4

Subacromial decompression

Answer 4

Performed when conservative treatment of impingement failed.
Can be open (deltoid detached), mini open (deltoid split), or arthroscopic. May include acromioplasty, bursectomy, removal of distal clavicle, and release of coracoacromial ligament.
Sling used for 1-2 weeks. Rehab focuses on pain control and gentle ROM and progresses to strength training.

Question 5

Rotator cuff repair

Answer 5

Usually arthroscopically or though an open or mini-open.
Immobilized in sling for several weeks.
Rehab includes passive and active-assisted ROM initially with strengthening later.
Precautions include no AROM, lifting, or weight bearing through arm for several weeks.

Question 6

Shoulder stabilization surgeries

Answer 6

Capsular shift procedure performed with chronic shoulder instability.
Tightening of joint capsule by cutting the capsule and overlapping the ends to reduce capsular redundancy.
There is also an electrothermally assisted capsular shift procedure used to shrink and tighten capsule.
Sling will be used and certain movements will be avoided depending on part of capsule repaired.
AROM can begin soon after surgery. Do not need to wait for full ROM to begin strengthening.

Question 7

Hip ORIF

Answer 7

Fracture of the femoral neck, intertrochanteric region, or subtrochanteric region.
Surgery is open. May affect TFL, glut med, and vastus lateralis depending on surgical approach.
Rehab includes ambulation and ROM, later strengthening.
Signs of fixation failure include persistent thigh or groin pain, leg length discrepancy that was not initially present, positioning the limb in ER, or trendelenberg that does not improve with strengthening.

Question 8

Surgery to fix articular cartilage defects

Answer 8

Microfracture procedures: penetrates subcondral bone, causing growth of fibrocartilage.
Osteochondral autograph transplantation: cartilage harvested from non-weight bearing surfaces to plug/fill chondral defects.
Autologous chondrocyte implant: healthy cartilage is harvested and cultured to grow and later implanted into cartilage defect.
Weight bearing and ROM restrictions.

Question 9

ACL reconstruction

Answer 9

Patellar tendon graft is strongest, but gracilis and semitendinousus are also common.
Period of immobilization with hinged brace locked in extension. Weight bearing restrictions. Quad and hamstring isometric and closed chain exercises.
Graft tissue most vulnerable at 6-8 weeks after surgery.
Graft maturation at 12-16 months post-op.
Return to sports usually around 6 months. In order to return to sports, must have no pain or effusion, full ROM, no instability, quad strength 85-90% of other side, hamstring strength 90-100% of other side, function testing like single leg hop 85-90% of other side.

Question 10

PCL reconstruction

Answer 10

Performed if pain and instability persist with therapy. Graft options similar to ACL reconstruction.
Rehab progression similar to ACL but more gradual weight bearing. Choose exercises that limit posterior shear and repeated knee flexion.

Question 11

Surgeries for meniscus injuries

Answer 11

Partial meniscectomy (torn piece removed; usually for older adults or when tear in inner two-thirds of meniscus) or repair of meniscus where tear is sutured back together. (usually for younger patients or when tear is outer-third of meniscus).
Meniscus repair: Restricted weight bearing and bracing. Limit ROM, especially flexion.
Partial meniscectomy: full weight bearing without use of brace. Faster recovery time.

Question 12

Lateral ankle reconstruction

Answer 12

Often after tear of ATFL or calcaneofibular ligament or chronic ankle instability.
2 approaches that are both open.
1) repairs torn ligaments via sutures.
2) harvesting autograph (usually peroneal brevis) to replace torn ligaments.
May include subchondral drilling due to chondral lesions.
Usually a cast then boot for several weeks then a brace.
Weight bearing restrictions. Rehab focuses on increasing ROM and then strengthening.

Question 13

Achilles tendon repair

Answer 13

Usually arthroscopic if performed a few days after injury. May need to be open if repair is delayed. Augmentation with use of graft may be needed (flexor hallucis longus, peroneus brevis, plantaris).
Usually casted in slight PF and non-weightbearing. Transition to boot with ankle in neutral and partial weight bearing. Be cautious of exercises that stretch Achilles and require active PF.

Question 14

Total Hip Arthroplasty

Answer 14

Usually performed due to arthritis, developmental dysplasia, tumors, or failed reconstruction of hip.
Rehab includes ankle pumps, heel slides, quad sets, glut sets, isometric abduction.
Should be able to extend hip to neutral and flex hip to 90 at time of discharge from hospital.
Cemented allows for partial weightbearing. Noncemented allows for toe touch WB for 6 wks.
Lifespan of prosthesis is about 20 years.

Question 15

Anterolateral approach

Answer 15

Access hip between TFL and glut med muscle. Portion of hip abductors are released from greater trochanter and hip is dislocated anteriorly.
Precautions: avoid hip flexion beyond 90 deg, extension, lateral rotation, and adduction.

Question 16

Direct lateral approach

Answer 16

Division of TFL and vastus lateralis and release of anterior portion of glue med. Posterior soft tissue and capsules intact so less likely to dislocate after surgery; may be best for non-compliant patients.
Precautions: avoid flexion beyond 90 deg, extension, lateral rotation, and adduction.

Question 17

Posterolateral approach

Answer 17

Splits glut max and releases short external rotators and hip abductors retracted. Dislocated posteriorly. Most common approach but high dislocation rate.
Precautions: avoid flexion of hip beyond 90 deg, adduction, and medial rotation.

Question 18

Total knee arthroplasty

Answer 18

Usually due to arthritis and destruction of articular cartilage.
Knee immobilization, elevation, cryotherapy, intermittent ROM using continuous passive motion (CPM)
cemented allows partial WB or WB as tolerated.
Noncemented requires toe touch WB for up to 6 wks.
Mobility, anke pumps, quad sets, hamstring sets, ROM, and stretching. Should have 90 deg knee flexion and 0 deg extension before discharge from hospital.
For several months, avoid squatting, quick pivoting, no pillow under knee, avoid low seating.
Outpatient rehab should include strengthening and closed chain exercises and functional activities.
Life expectancy of prosthesis is 15-20 years.