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A new approach to knee Rehabilitation ( OSTEOTOMY) Z .Ghasempour MS PT

Management of Knee Disorders & Surgeries Joint Hypomobility: *Nonoperative Management *Joint Surgery &Postoperative Management

Nonoperative Management Common Joint Pathologies and Associated Impairments Postimmobilization Hypomobility *OA and RA and Develop Decreased Flexibility& Adhesions Reflexed inhibition Quadriceps

JOINT SURGERY AND POSTOPERATIVE MANAGEMENT Repair of Articular Cartilage Defects Synovectomy Total Knee Arthroplasty Osteotomy

Rehabilitation Guidelines Pre-operative Post-operative Recommendations

Multicenter Ortopaedics Outcomes Network Important points Normal gait AROM 0 to 90 degrees of flexion Strength: 20 SLR with no lag Minimal effusion Patient education on post-operative exercises and need for compliance Educated in ambulation with crutches Wound care instructions Multicenter Ortopaedics Outcomes Network

Contusion / Edema Multiple splits strips 4-8 strips (with 2”) No stretch Great for TKA’s

Begin VMO and Quadriceps strengthening 1- Quadriceps setting 2- Multi-plane straight leg raising 3- Open kinetic chain multi-plane hip strengthening Gait training; protected weight-bearing as instructed

Strength Exercises: Quadriceps Contraction Straight Leg Raises

Strength Exercises: Hip Adduction Gluteals

Strength Exercises: Hamstrings Squats (Quadriceps) Single leg squats

What is the optimal postoperative treatment ? Scientific evidence Moffet et al.149 conducted a single-blind, randomized controlle d study to determine the effectiveness of an intensive , supervised functional training program initiated 2 months after primary surgery for OA. The investigators concluded that an intensive, oriented exercise program initiated functionally 2 months after surgerywas safe and effective for improving physical function and quality of life.

OSTEOTOMY—Interventions for Each Phase of Rehabilitation Weeks 1–4 )Maximum Protection Phase Patient enters rehabilitation 1–2 days postoperatively(Inpatient Acute Care) • Postoperative compression dressing • Postop pain controlled • ROM 10–60 • Weight bearing as tolerated

Key examination Goals & procedures Pain (0–10 scale) • Monitor for hemarthosis • ROM • Patellar mobility • Muscle control • Soft tissue palpation • Control postoperative swelling • Minimize pain • ROM 0–90 • 3/5 to 4/5 muscle strength • Ambulate with or without assistive device • Establish home exercise program

Pain & effusion management Cryo-therapy Elevation Compression Anti-inflammatory medication

Interventions Pain modulation modalities • Compression wrap to control effusion • Ankle pumps to minimize ris k of DVT • A-AROM and AROM • Muscle setting quadriceps,hamstrings, and adductors (E-stim) • Patellar mobilization (grades I and II) • Flexibility program hamstrings, calf, IT band • Gait training • Trunk/pelvis strengthening

ROM exercise Knee extension to 0 degrees after surgery Prevent a flexion contracture Hip AROM exercise 4 planes

Protocols after OSTEOTOMY Time frames and guidelines after OSTEOTOMY reconstruction vary widely. Most protocols emphasize Early motion Developing quadriceps control early Obtaining full passive extension Controlled weight bearing Initiation of closed-chain exercises

Moderate Protection Phases: Weeks 4–8

Moderate Protection Phases: Weeks 4–8 • Minimum pain • Full weight bearing except with uncemented or hybrid • ROM 0–90 • Joint effusion controlled

Key examination Goals & procedures Pain assessment • Joint effusion—girth • ROM • Patellar mobility • Gait analysis • Reduce swelling • ROM 0–110 or more • Full weight bearing • 4/5 to 5/5 strength • Unrestricted ADL function • Adherence to home exercise program

Interventions Patellar mobilization • stretching program • Closed-chain strengthening • Limited range PRE • Tibiofemoral joint mobilization, if appropriate and needed • Proprioceptive training • Stabilization exercises • Gait training • Protected aerobic exercise—swimming, cycling or walking

Criteria for Progression Quadriceps control (ability to perform good quad set and SLR). Full passive knee extension. Passive ROM 0-90 degrees. Good patellar mobility. Minimal joint effusion. Independent ambulation. Swelling Control Ice, compression, elevation

keep moving! Walk outside your home 3 to 5 times each day 9/18/2018 Z.GHASEMPOUR,MS,PT

Stair Climbing and Descending 9/18/2018 Z.GHASEMPOUR,MS,PT

Stair Climbing and Descending The ability to go up and down stairs requires strength and flexibility. Always lead up the stairs with good knee & down the stairs with operated knee. Remember, "up with the good" and "down with the bad.“ 9/18/2018 Z.GHASEMPOUR,MS,PT

Minimum Protection/Return to Function Phases: Beyond Week 8

Minimum Protection/Return to Function Phases Muscle function: 70% of noninvolved extremity • No symptoms of pain or swelling during previous phase

Controlled Ambulation Goals Restore full knee ROM (0-120°). Improve lower extremity strength. Enhance proprioception, balance, and neuromuscular control. Restore limb confidence and function.

Key examination Goals & procedures Pain assessment • Muscular strength • Patellar alignment/stability • Functional status • Develop program and educate patient on importance of adherence including methods of joint protection • Improve cardiopulmonary endurance/aerobic fitness

Interventions Continue as previous phase; advance as appropriate • Implement exercise specific to functional tasks

Single leg stance (eyes open, eyes closed) Double leg squats on an unstable surface (thick carpet, foam block, camping mattress) Single leg stance on an unstable surface

Proprioception

Proprioception drills. KNEE UP & HOLD

Continuous Passive Motion CPM is not warranted to improve rehabilitation outcome

Keys to the Early Phases of Rehabilitation Following Surgery Diminish Pain and Inflammation Restore Full Knee Extension Motion Gradually Progress Knee Flexion Motion Maintain Patellar Mobility Restore Quad Control Restore Independent Ambulation

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