Rehabilitation For The Postsurgical Orthopedic Patient Mitchell Goldflies, MD

Rehabilitation For The Postsurgical Orthopedic Patient

Mitchell Goldflies, MD

Musculoskeletal Conditions

• Etiology– Acute– Overuse– Degenerative

• Primary Lesions• Secondary Lesions

– Biomechanics– Ergomonics– Training Errors– Body Composition– Innervation-Referral Pattern

Musculoskeletal Conditions

• Evaluation Includes– Medical Condition– Mental Condition– Nutritional Status– Family History– Past Medical History– Litigation– Secondary Gain– Compliance– Belief System

Soft Tissue Healing Following Trauma and Surgery

• Surgery is Controlled Trauma Produced By a Trained Professional To Correct Uncontrolled Trauma

• Connective Tissue Responds in a Characteristic Way to Immobilization and Trauma

• Connective Tissue is 16% of Body Weight and 25% of Body Water Content

Soft Tissue Healing Following Trauma and Surgery

• Connective Tissue– Ligament– Tendon– Perisoteum– Joint Capsule– Aponeurosis– Nerve– Muscle Sheath– Blood Vessel Wall– Bed and Framework of the Internal Organs

Soft Tissue Healing Following Trauma and Surgery

• Connective Tissue Components– Cells– Extracellular Matrix– Fibroblast

• Synthesizes Inert Components – Collagen– Elastin– Reticulin– Ground Substance

Soft Tissue Healing Following Trauma and Surgery

• Connective Tissue Types– Dense Regular: Ligaments and Tendons– Dense Irregular: Joint Capsule, Perisoteum,

Aponeurosis– Loose Irregular: Fascia, Muscle, Nerve

Sheath

Soft Tissue Healing Following Trauma and Surgery

• Connective Tissue Biomechanics– Viscoelastic

• Elastic-Temporary Deformation• Viscous-Plastic-Permanent Deformation

– Shock Attenuation

• Immobilization– Fibrofatty Infiltration– Fibrous Adhesions– Dehydration

Soft Tissue Healing Following Trauma and Surgery

• Remobilization– Well Ordered Collagen Along The Lines of

Force– Reduction in Cross Links– Production of Ground Substance– Rehydration– Adhesions Rupture

Bone Healing Following Trauma And Surgery

• Stages of Healing: Overlap– Inflammatory Phase 10%– Repair 40%

• Removing Debris

– Remodeling 70%– Results

• Restoration of Original Tissue• Scar• Excessive Repair• Failure of Healing

Bone Healing Following Trauma And Surgery

• Injury Variables– Type of Injury– Intensity and Duration of Force– Tissues Involved– Patient Age– Nutritional Status– Genetic, Systemic and Local Disease– Smoking

Bone Healing Following Trauma And Surgery

• Management– Resuscitation of Patient– Clinical Assesment– Debridement if Open– Reduction

• Manipulation• Traction• Operative Reduction

Bone Healing Following Trauma And Surgery

• Management– Immobilization

• Prevent Displacement or Angulation• Prevention of Motion

– Rigid– Controlled Motion

• Relief of Pain

Bone Healing Following Trauma And Surgery

• Energy (High or Low)• How Force Applied (Direct or Indirect)• Level

– Articular– Metaphsyeal– Diaphsyeal

• Soft Tissue• Bone Deficits• Associated Conditions (Smoking, Diabetes,

PVD, Bone Disease, Steroids, NSAIDS)

Bone Healing Following Trauma And Surgery

• Procedure– Closed – Percutaneous– Limited Open– Open

• Fixation– Internal– External– Combined

Bone Healing Following Trauma And Surgery

• Fixation– Rigid– Flexible– Bioabsorable

• Graft Material– Synthetic– Allograft– Autograft– Xenograft

Bone Healing Following Trauma And Surgery

• Bone Stimulation– Ultrasound– Pulsed Magnetic Field– Implanted Direct Current

Bone Healing Following Trauma And Surgery

• Wound– Closed– Drains– Flaps– Open

• Packed• Wound Vac• Bead Pouch• Special Considerations

Rehabilitation FollowingBone Healing

• Rehabilitation is The Business of the Entire Medical Team

• Reduction and Immobilization May Be Unnecessary

• Rehabilitation is Always Essential– Preserve Function During Healing– Restore Function After Healing

Rehabilitation FollowingBone Healing

• Prime Goals of Rehabilitation– Maintain or Restore The Range of Motion of

Joints– Preserve Muscle Strength and Endurance– Enhance the Rate of Fracture Healing by

Activity– Early Return Function and Employment

Postoperative Rehabilitation

• Methods of Rehabilitation– Active Use– Active Exercises– Under Supervision of a Physical Therapist

• Phases– 1. Return to Range of Motion– 2. Regain Muscle Strength Strength– 3. Endurance and Functional Progression

Rehabilitation FollowingBone Healing

• Active Use– The Patient Must Continue to Use the Injured

Part as Naturally as Possible Within The Limitations Imposed by Necessary Treatment

– Rest May be Necessary for Days or Weeks

• Active Exercises– Muscles– Joints

Rehabilitation FollowingBone Healing

• Active Exercises– Muscles

• Isometric Exercise If Immobilization Present• Isotonic Exercise When Immobilization Removed

– Protected Range of Motion» Direction» Range

• Isokinetic Exercise

– Joints• Capsular Contracture• Capsular Laxity• Functional Instability

Rehabilitation FollowingBone Healing

• Active Exercises– Edema Control– Disuse Atrophy– Sympathetic Nervous System Dysfunction

• Complex Regional Pain Disorder• Reflex Sympathetic Dystrophy• Causalgia

Rehabilitation FollowingBone Healing

• Active Exercises– Contralateral Limb Rehabilitation– Joint Stabilization– Joint Range of Motion– Muscle Strength– Balance Sense-Proprioception– Endurance– Activity Specific Reeducation

• Continuous Passive Motion

Rehabilitation FollowingBone Healing

• Gait Training– Wheelchair– Scooters– Walker– Crutches– Cane

• Gait Patterns

• Weight Bearing Status

Rehabilitation FollowingBone Healing

• Modalities– Heat

• Hot Packs• Ultrasound• Diathermy• Whirlpool

– Cold– Contrast Baths

Rehabilitation FollowingBone Healing

• Modalities– E-Stim– TENS– Microcurrent

• Massage

• Orthotics

Where Surgical Services Provided: Outpatient vs. Inpatient

• In Community (On Field)• Emergency Room

– Monitored Bed

• Hospital Surgical Suite• Bedside• Hospital Based Outpatient Office Center• Free Standing Ambulatory Surgery Center• Private In-Office Procedure

Arthroscopic and Endoscopic Procedures

• Arthroscopy– Hip– Knee– Ankle– Subtalar Joint– Great Toe MPJ

Arthroscopic and Endoscopic Procedures

• Endoscopy– Spine– Carpal Tunnel– Plantar Fascia– Morton’s Neuroma

Upper Extremity

Shoulder

• Fracture/ Dislocation– Clavicle/ A-C Joint– Glenohumeral Joint– Surgical Neck Humerus

• Repair/ Reconstruction– Acromio-clavicular Joint– Rotator Cuff

• Impingement• Tear

Shoulder

• Repair/ Reconstruction– Glenohumeral Joint

• Capsule• Labrum• Long Head Biceps

• Prosthesis– Hemiarthroplasy– Total Shoulder Arthroplasty

Shoulder

• First 3 Weeks After Surgery– Control Postoperative Inflammation and Pain– Protect Healing Soft Tissue– Minimize Effects of Immobilization

• Cervical, Elbow and Wrist Motion

• 3 to 6 Weeks After Surgery– Muscle Strengthening

• Scapular Stabilizers• Rotator Cuff

Shoulder

• 9 to 12 Weeks After Surgery– Enhance Kinesthesia and Joint Position

Sense– Build Endurance– Strength Scapular Stabilizers– Work or Sports Specific Tasks

Elbow

• Fracture/Dislocation– Humerus– Radial Head and Neck– Olecranon– Elbow Dislocation

• Repair/ Reconstruction– Distal Biceps Tendon– Ulnar Collateral Ligament– Tennis/ Golfers Elbow (Epicondylitis)

Elbow & Wrist

• Nerve Decompression– Elbow

• Radial Nerve at Arcade of Froshe• Ulnar Nerve at Cubital Tunnel

– Wrist• Median Nerve at Carpal Tunnel• Ulnar Nerve in Guyon’s Canal

Elbow Rehabilitation

• 1-14 Days After Surgery– Achieve Range of Motion of Adjacent Joints

• Passive• Active• Active Assisted

– Promote Wound Healing– Control Edema– Control Pain– Retard Muscle Atrophy

Elbow Rehabilitation

• 15-45 Days After Surgery– Control Edema and Pain– Achieve Full Range of Motion-Passive– Maintain Full Range of Motion of Adjacent

Joints– Promote Mobility of Scar Tissue

Elbow Rehabilitation

• 4-6 Weeks After Surgery– Control Pain– Maintain Full Elbow and Forearm Range of

Motion– Strengthen Upper Extremity– Regain Normal Forearm Flexibility

Wrist and Hand

• Fracture/ Dislocation/ Sprain/ Strain– Wrist

• Colles• Smith• Barton’s• Scaphoid

– Hand• Metacarpal (Boxer, Bennett’s)• Finger (Crush, Mallet, Jersey, Volar Plate)

Hand and Wrist Rehabilitation

• Weeks 1-3: Inflammatory Phase– Decrease Pain– Manage Edema– Improve Active Range of Motion of Upper

Extremity– Initiate Self Management and Patient

Education

Hand and Wrist Rehabilitation

• Weeks 4-6: Proliferation Phase– Self Management of Symptoms– Return to Work Activities

• After 6 weeks Following Surgery– Remodeling and Maturation of Scar

Spine• Fracture/ Subluxation

– Osteoporotic Compression Fracture– Pars Fracture (Spondylolysis) – Spondylolithesis

• Reconstruction– Discectomy– Fusion– IDET/ Endoscopic Spine

Spine Rehabilitation

• Weeks 1-3: Protective Phase– Protect Surgical Site to Promote Wound

Healing– Maintain Nerve Root Mobility– Reduce Pain and Inflammation– Educate Patient

• Body Mechanics• ADL• Self Care

Spine Rehabilitation

• Weeks 4-6: Functional Recovery Phase– Educate in Neutral Spine Concept– Cardiovascular Conditioning– Increase Trunk Strength– Increase Soft Tissue Mobility– Increase Lower Extremity Flexibility &

Strength– Maintain Nerve Root Mobility

Spine Rehabilitation

• Weeks 7-12: Resistive Training Phase– Independent in ADL and Self Care– Increase Activity Tolerance– Return to Normal Functional Level

Lower Extremity

Pelvis and Hip

• Fracture/Dislocation– Pelvis

• Ring• Acetabulum

– Hip• Intracapsular• Extracapsular

Hip and Knee

• Joint Reconstruction– Osteotomy– Fusion

• Joint Arthroplasty– Resection (Girdlestone)– Resurfacing– Hemiarthroplasty– Total Joint Replacement

Hip and Pelvis Rehabilitation

• Preoperative Training – Gait Training– Transfer Techniques

Hip and Pelvis Rehabilitation

• Postoperative Days 1-2– Prevent Complications– Increase Muscle Contraction and Control– Positioning Precautions– Up in Chair– Transfers– Ambulation

Hip and Pelvis Rehabilitation

• Postoperative Days 3-7– Prevent Complications– Positioning Precautions– Promote Transfers– Gait Independence– Discharge to Rehab or Home

Hip and Pelvis Rehabilitation

• Postoperative Weeks 1-6– Positioning Precautions– Improve Hip & Lower Extremity

• ROM• Strength• Balance

Hip and Pelvis Rehabilitation

• Postoperative Weeks 1-6– Increase Independence In

• Transfers• Gait

– Plan Return to • Home• Work• Previous Activities

Knee

• Fracture– Supracondylar Femur– Patella– Tibial Plateau

Knee

• Acute Dislocation/ Sprain/ Strain– Ligament

• Collateral• Cruciate

– Meniscus

• Degenerative– Meniscus– Patello-Femoral– Femoral/ Tibial

Knee Rehabilitation

• Preoperative Training – Gait Training– Attempt to Resolve

• Inflammation• Swelling• Pain

– Exercise to Regain• Rom• Strength• Balance Sense (Proprioception)

Knee Rehabilitation

• Acute Phase: Post-op 1-2 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Passive & Active ROM– Joint Mobilization

Knee Rehabilitation

• Acute Phase: Post-op 1-2 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Passive & Active ROM– Joint Mobilization

Knee Rehabilitation

• Subacute Phase: Post-op 3-4 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities

• Stand to Sit

– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Active ROM– Joint Mobilization and Stabilization

Knee Rehabilitation

• Advanced Phase: Post-op 5-6 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities

• Gait Training • Reduce Reliance on Ambulatory Aids

– Joint Mobilization and Stabilization– Progress Exercise Program

Knee Rehabilitation

• Upgrade Phase: Post-op >7 Weeks– Progress Exercise Program– Return to Activities– Ongoing Training Program

Foot and Ankle

• Trauma (Acute and Overuse)– Sprains and Strains

• Achilles• Lateral Ankle• Plantar Fascia

Foot and Ankle

• Fractures/ Dislocations• Ankle• Os Calcis• 5th Metatarsal Base• Lisfrac Fracture/Dislocation• Metatarsal Stress Fracture• Toe crush and fracture

Foot and Ankle Rehabilitation

• Post-op Initial Immobilization 4-6 Weeks– Gait Training– Contralateral Lower Extremity Rehab– Cardiovascular Training

Foot and Ankle Rehabilitation

• Phase 1 Rehab 2-6 weeks Post-op– Decrease Pain & Swelling– Restore Joint and Soft Tissue Mobility– Protected ROM

• Bracing

– Increase Strength in Lower Extremity– Increase Proprioception– Normalize Gait– Maintain Cardiovascular Fitness– Patient Education

Foot and Ankle Rehabilitation

• Phase 2 Rehab 6-8 weeks Post-op– Decrease Pain & Swelling– Restore Normal Joint ROM– Increase Strength in Lower Extremity

• Intrinsic and Extrinsic Foot & Ankle Muscles

– Increase Proprioception– Normalize Gait– Maintain Cardiovascular Fitness– Bracing

Foot and Ankle Rehabilitation

• Phase 3 Rehab 8-10 weeks Post-op– Prevent Pain & Swelling– Maintain Normal Joint ROM

• Mobilization• Passive Stretching

– Increase Strength and Endurance– Increase Balance & Proprioception– Focus Training on Return to Work and Sports– Bracing/ Orthotics

Foot and Ankle Rehabilitation

• Phase 4 Rehab >10 weeks Post-op– Maintain Joint ROM– Increase Strength and Endurance– Increase Balance & Proprioception– Return to Work & Sports Activities– Bracing/ Orthotics

Thank You