1. به نام خداوند بخشنده مهربان

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

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

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

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

7. Rehabilitation Guidelines
Pre-operative
Post-operative
Recommendations

8. 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

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

10. 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

11. Strength Exercises:
Quadriceps Contraction
Straight Leg Raises

12. Strength Exercises:
Hip Adduction
Gluteals

13. Strength Exercises:
Hamstrings
Squats (Quadriceps)
Single leg squats

14. 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.

15. 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

16. 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

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

18. 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

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

20. 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

21. Moderate Protection Phases: Weeks 4–8

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

23. 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

24. 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

25. 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

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

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

28. 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

29. Minimum Protection/Return to Function Phases: Beyond Week 8

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

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

32. 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

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

34. 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

35. Proprioception

36. Proprioception drills.
KNEE UP & HOLD

37. Continuous Passive Motion
CPM is not warranted to improve rehabilitation outcome

38. 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

39. THANK YOU