Orthopedic Surgical Procedure

A. Definition

- Is the medical specialty that includes the investigation, preservation and

restoration of the form and function of the extremities, spine and
associated structures by the medical, surgical and physical methods.

B. Classification

Shoulder

I. Shoulder Arthroplasty

- Is a surgical procedure for restoring motion to a stiffed joint as well as the

necessary stability of the joint and eliminate joint pain.

3 Basic types of Arthroplasty

a. Replacement arthroplasty

- One or both joints are replaced by prosthesis, usually metal, plastic or the
most frequently used, a combination of both.

b. Interpositional arthroplasty

- It involves insertion of a substance such as fascia, skin, plastic, or metal

between the 2 joint surface.

c. Excision arthroplasty

- Removal of a periarticular bone from one or both joint surface leaving a

gap of 2 cm

Indications

- Intractable pain at rest or in motion associated with RA or DJD

- Severe loss of UE strength and function

- Decreased ROM

Contraindications

- Active infection

- Patients with neuropathic joints

- Young heavy laborers who are unwilling to change their lifestyle

Complications

- Proximal migration of the humeral component

- Infection

- Instability

PT management

- Operated shoulder is immobilized with the arm in a sling positioned in

adduction, IR and slight forward flexion of 10-20 degrees

Maximum protection phase

Duration: 1-3 weeks

a. Maintain normal motion and to minimize muscle guarding and spasm,

relax and gently massage the neck, shoulder and scapula.

b. To maintain normal hand, wrist and elbow function, begin active exercises
to these areas immediately after surgery

c. Continous Passive Motion to the shoulder

d. Gentle Pendulum Exercise without weights

e. Passive and AAROM emphasizing flexion, scaption, abduction to 90 with

arm IR and elbow flex

Moderate Protection Phase

Duration: 2-6 weeks post op

a. To regain control of shoulder girdle muscles, progress from AAROM to

active shoulder motions

b. To increase strength, isometric exercise against minimal resistance

Minimum Protection Phase

Duration: 4-6 weeks post op

a. To strengthen shoulder girdle, begin PRE using therabands or hand held

weights emphasizing on low loads and high repititons

b. To develop stability, begin CKC UE exercises

c. To improve ROM, gentle stretching exercises using hold relax techniques

or low load prolonged stretch
II. Shoulder Hemireplacement

Indications

- Fracture or dislocation of proximal humerus

- Severe pain due to arthritis of the head of the humerus

PT Management

- Arm is immobilized and supported at the side with a sling

- Same with Shoulder Arhtroplasty

III. Shoulder Arthrodesis

- Is a surgical resection of GH surfaces and fusion. It is occasionally

recommended because of the fear of rapid mechanical loosing of an
overused shoulder arthroplasty.

Indications

- Severe pain

- Gross GH instability

- Complete deltoid and rotator cuff paralysis

- Good compensatory scapular motions and strength of the serratus

anterior traps

PT Management

- Maintain mobility in the wrist and hand while shoulder is immobilized

- Active elbow flexion and extension through full range if brace with hinged
elbow is used

IV. Rotator Cuff Tears

- It is a condition that typically occurs over the age of 40 following the

repetitive microtrauma to the rotator cuff or long head of the biceps.
 3 Progressive Stages

1. Stage 1 – edema and hemorrhage seen below the age of 25

2. Stage 2 – fibrosis and tendonitis, seen between 25-40 years

3. Stage 3 – Bone spurs, rotator cuff tears and biceps rupture over 40 yrs
old

Indications

- Partial or full thickness tears of rotator cuff tendons associated with

irreversible degenerative changes in soft tissue

- Chronic impingement and partial thickness tears with the weakness and
atrophy in external rotators

- Full thickness traumatic tears

PT Management

- Shoulder is immobilized in abduction and IR with arm supported in

abduction splint for 4-6 weeks.

Maximum Protection Phase

- PROM or AAROM of shoulder through pain free range of 90-120. CPM may
be used after surgery.

- Begin submaximal isometric exercise with small pillow under the axilla to
protect the reattached tendons

- Rhythmic stabilization exercises for scapular muscles against pain free

level of resistance

- Pendulum, gear shift and wand exercises

Moderate and Minimum Protection Phase

- To restore adequate muscle strength

- Active arm movements to strengthen scapular muscles such as the

serratus anterior and trapezius muscle

- Full active overhead shoulder flexion should not be initiated for 6 weeks to
allow adequate healing time of reattached tissues

- Begin isotonic strengthening of shoulder muscles with elastic resistance

and weights when patient has achieved full active pain free motion
Elbow

I. Radial Head Excision

- Most common fracture of the elbow is the fracture of the radial head. If
displacement occurs or fracture is comminuted, radial head excision is
indicated.

Indication

- Severe comminuted fracture

- Fracture dislocation of the head of the radius as a result to fall on

outstretched hand

- Chronic synovitis and mild deterioration of the articular surface associated

with arthritis

Maximum Protection Phase

- To maintain elbow mobility, perform PROM within pain free ranges

- Do submaximal pain free multiple angle isometrics of elbow muscles to

decrease atrophy

- AROM to the shoulder wrist and hand joints to maintain mobility

Moderate and Minimum Protection phase

- Begin AAROM over next 3-6 weeks

- Avoid lifting heavy objects with the operated arm and hand

- Full joint activity is allowed by 6 weeks post op

- High intensity and speed training activities in functional movement

patterns are indicated for individuals wishing to return to high demand
recreational activites

II. Total elbow Arthroplasty

- Replacement of the articulating surfaces of the distal humerus and

proximal ulna of the elbow.

Indications

- Pain and articular destruction of the HU and HR joints

- Marked LOM of the elbow

- Gross instability of the elbow

- Bone stock loss from trauma or tumor

Contraindications

- Active infection

- Young patients with active lifestyle

- Loosening of the components

- Instability

- Ulnar nerve injury

Maximum Protection Phase

Duration: 3-5 days

- Arm is elevated in bed or supported in a sling when patient is upright

- To minimize edema in the hand and maintain motion to associated joints,

active finger hand and wrist exercises are performed

- Active assistive flexion and passive extension of elbow with arm in

supination, pronation and mid position

- Active supination and pronation of forearm with elbow in 90

Moderate and Minimum Protection Phase

- 8-10 days, elbow is supported in splint in maximum comfortable extension

- 3-4 weeks, active anti gravity elbow extension

- 6 weeks, start gentle isotonic resistance exercise and partial weight

bearing closed chain activities

III. Elbow Arthroscopy

Indications

- Loose bodies
- Chondromalacia of radial h ead

Contraindications

- Bony ankylosis

- Severe fibrous ankylosis

PT Management

- Wear a sling for comfort

- AAROM exercises for first post op day

- Progress to full ROM

Wrist

I. Total Wrist Arthroplasty

Indications

- Severs instability of the wrist joint, deterioration of the distal radius, ulna
and carpals

- Bilateral wrist involvement in which arthrodesis would limit both wrist

function

- Sublaxation or dislocation of the radiocarpal joint

- Severe wrist pain

Contraindications

- Loosening of distal components

- Dislocation of the prosthesis

- Active infection

PT Management

- Hand and wrist are placed in a bulky dressing for 3-6 days post op and
elevated to reduce edema

Maximum Protection Phase

- Patient is advised to frequently do active finger flexion and extension

exercises in the splint or casts to maintain finger mobility and reduce
edema
Moderate and Minimum Protection Phase

- Wrist splint is worn between exercise sessions during the day for 6-8
weeks, worn at night for 12 weeks

- Full use of hands for light activites is permissible by 12 weeks post op

- Gentle resistance exercise begin 6-8 weeks to improve grip

- AROM is continued until functional Rom is achieved

Hip

I. Hip Joint Arthrodesis

- The cartilaginous surface of the anterior and most of the middle and
posterior aspect of the femoral head as well as part of the acetabulum is
removed and attached together with pins

Indications

- Joint destruction due to pyogenic septic arthritis

- Unilateral painful hip with restricted ROM

- OA due to congenital hip dysplasia

- Osteonecrosis of the hip

- Post traumatic arthritis

- Hip infection

Complications

- Injury to the blood vessels and nerves

- Loosening of internal fixation devices

- Accelerated degenerative changes

- Leg length shortening

- Femur fractures

- Pseudoarthritis

Post Op Management

- Cast immobilization until evidence of solid fusion appears

- Internal Fixation should be removed 1 yr after solid fusion

- Weight bearing is allowed after 12 weeks

II. Hemi-Replacement of the Hip

Indications

- Degeneration of femoral head, with normal acetabulum

- Subcapital fracture of femoral head

Post Op Management

- Avoid exercises the impose greatest compression or shearing force to the

joint

- Exercises are similar to Post op Management of THR

- Avoid SLR and gluteal setting exercise

III. ORIF of the Hip

Indications

- Subcapital femoral neck fracture

- Fracture of proximal femur

- Intertrochanteric fracture

- Subtrochanteric fracture

Post Op Management

- Advise patient to get up and move quickly as possible. Internal Fixation

allows early movement and weight bearing on the involved extremity.
Minimizes the complications of edema, muscle atrophy, contractures and
osteoporosis

- No need for external immobilization

After Internal Fixation

- Muscle setting exercises to minimize muscle atrophy

- AAROM and AROM exercises of involved hip to maintain mobility

- Active ankle exercises to maintain circulation

- Resisted knee flexion and extension to maintain strength

- Open and closed chain active resistive exercises to enhance gait training

- Progress to closed chain exercises of involved extremity

Knee

I. Synovectomy

Indications

- Chronic synovitis and pain of the knee lasting for 6 month or longer

- Synovial hypertrophy and joint pain

- Intact articular surfaces

- Decreased range of motion

PT Management

- Knee is immobilized 24-48 hrs in a bulky compressive dressing and a

posterior splint

- Leg is elevated to decrease edema

Maximum Protection Phase

- To regain control and strength of the knee muscles, begin submaximal

multiple angle isometrics

- Begin joint mobilization and soft tissue stretching

- Patient is encouraged to resume low impact, low intensity progressive

conditioning activities

II. Intra articular ACL reconstruction

Indications

- Severe acute tear and chronic insufficiency of the ACL

- Partial tear that results to limitation of functional activities

- Failed conservative management of ACL tear

PT Management

- Knee is placed in a controlled motion brace locked in extension or slight

flexion. Immobilized for 4-6 weeks. CPM is initiated within safe ROM
surgery.

Maximum Protection Phase

- To control edema or pain, use ice, massage and compression

- To prevent muscle atrophy, initiate electrical stimulation, SLR, quads and

hams setting exercise

- Prevent contracture

- Initiate ambulation with crutches with weight bearing with the motion
controlled brace locked in extension

Moderate Protection Phase

- To increase ROM and endurance of hip muscles, do open and closed chain
eccentric and concentric exercises

- Hamstring strengthening is emphasized to maximize dynamic stability of

posterior aspect of the knee

- Avoid closed chain squatting exercises between 60-90 flexion and open
chained terminal knee extension

Minimum Protection Phase

- Emphasis is on light functional activities

- Pylometrics may also be applied

- Functional bracing may still be required during in high demand

recreational activities

Ankle and Foot

I. Total ankle Joint Replacement

Indications

- Severe tibiotalar joint deterioration and pain

- Marked LOM of the ankle joint

- AVN of ankle joint due to repetitive ankle injury

Contraindications

- Very unstable ankle

- Vascular deficiency

- Inadequate bone density

- Muscle imbalance

PT Management

- Biological Fixation – ankle is immobilized in neutral position in cast up to 6

weeks

- Cement Fixation – ankle is immobilized in a bulky compression dressing

for 3-5 days

Maximum Protection Phase

- Begin isometric exercise of the ankle musculature, gluteal and quads

muscle

- Initiate active open chained DF and Pf

- Begin resistive exercise in preparation for walking

Moderate Protection Phase

- Do elastic resistance exercise against elastic tubing to strengthn ankle

muscles in an open chain

- To strengthen ankle muscles in a close chain, begin active and resisted

ankle exercises on a balance board in a seated position

- To stretch the PF, add towel stretches in a long sitting position

II. Arthrodesis of the Ankle and Foot

- Provides pain free weight bearing and stability of the ankle to the person
with high functional demands but sacrifices the mobility of one or more
joints of the ankle

Indications

- Severe articular damage and pain with weight bearing

- Instability of a weight bearing joint

- Deformity of toes, foot or ankle

- Patients with high functional demands and pain free compensatory

movements in adjacent joints

Post Op Management

- The fused joints are immobilized in plaster of skeletal pins for 6-12 weeks.
Patient must be non weight bearing. Gait training with assistive is
necessary. To maintain mobility, AROM is performed. Patient is advised of
proper shoe selection.

III. Common Ligament tears

- A third degree sprain of the lateral ankle, which occurs as a result o

severe inversion sprain, often causes complte tears of the anterior
talofibular and calcaneofibular ligaments. A complete tear of one or more
ligaments can cause marked instability and impaired functional activities
of an individual

Indication

- 3rd degree lateral ankle sprain

- Complete tear of ATF or CF ligaments

- Gross instability of the ankle

PT Management

- Ankle is immobilized in a short leg cast brace in 0 DF and slight eversion

for 6-8 weeks. Must be non weight bearing on the operated LE. Foot must
be elevated when in supine to minimize edema

Maximum Protection Phase

- Perform active or gentle resisted exercise of the hip and the knee on the
involved side to maintain strength of LE

- Gentle pain free muscle setting to he ankle musculature

Moderate and Minimum Protection Phase

- Restore ROM of the ankle with grade 3 joint mobilization but avoid stretch.
Emphasize restoration of DF and PF before inversion and eversion.

- Increase strength in open chain and close chain positions

- Retrain balance and postural control in a balance board

- Patient can return to full activity by 4-6 months

IV. Complete Rupture of the Achilles Tendon

- Occurs as a result of eccentric contraction of the gastrocnemius and

soleus muscle, frequently on adults with compromised blood supply to the
tendon

Indication

- Complete rupture of the Achilles tendon cannot be achieved by

conservative means

PT Management

- Ankle is immobilized in a short leg cast for 3-4 weeks positioned in PF.
Patient must remain weight bearing on affected side and ambulate with
crutches

Maximum Protection Phase

- Begin submaximal muscle setting

- As healing occurs, increase intensity of isometric exercise

- Maintain strength of the hip and knee on the affected side

Moderate and Minimum Protection Phase

- Begin mobilization of the restricted joint and low intensity muscle

stretching

- Increase strength of the ankle in open chain multiple angle, isotonic

resistance exercises against elastic tubing

- Apply rhythmic stabilization exercises to improve balance and stability of

the LE

- Add functional activities like jogging, toe walking and pylometrics

- Patient return to full activity by 6-9 weeks

 Total Hip Replacement

I. Definition

- Is the most effective method of relieving pain and restoring movement in

hip affectation. This involves the replacement, by surgical mean, of a
severely damaged hip joint with an artificial one usually the acetabular
cartilage by a high molecular weight, high density polyethylene socket
and the femoral head by a metallic prosthesis

II. Epidemiology

- Is a relatively common procedure, with an estimated of 75,000 THR’s

performed on 65,000 patients annually in the US. About 65% of the
procedures are performed on patients over 65 yrs old, with another 25%
performed on patients between 55-64 yrs old.

III. Etiology

Indications

- Severe hip pain with motion and weight bearing as a result of joint
deterioration and loss of articular cartilage associated with RA, OA, AS and
AVN

- Marked limitation of hip motion

- Instability or deformity of the hip

- Failure of previous hip surgery

IV. Complications

Local

- Deep Infections

- Dislocations
 - Heterotrophic bone formation

- Fracture of he femur

- Perforation of the femur or acetabulum

- Vascular complications

Systemic

- Death

- Thromboembolic disease

- Urological complications

- Pulmonary, cardiovascular and GI complications

V. Prognosis

- THR, when done for incapacitating pain and dysfunction gives a

predictably excellent result. Relief of pain and return to useful function
can be expected. The usual patient can become independent within 3
months. Acetabular loosening may occur in 10% of the patients by the
tenth yr, and probably increase with time.

VI. Medical Management

PT Assessment

I. Assessment

- Determine the amount and type of pain, swelling or crepitation the patient
is experiencing

- Measure the AROM and PROM of the involved extremity

- Check the ROM of all the other joints

- Grade the strength of the affected extremity

- Estimate he strength of the affected joints or extremities as a basis for

post operative ambulation, transfers and ADL’s
 - Determine the level of functional independence that the patient had pre
op and the level that he expects post operatively

- Evaluate the gait characteristics, type of assistive device and degree of

weight bearing used during ambulation

II. Treatment and rationale of Management

1. Immobilization

- After surgery when patient is lying in the bed in the supine position, the
operated limb must remain in the position of slight abduction and neutral
rotation.

2. Exercise

Maximum Protection Phase

- Deep Breathing, coughing and ankle pumping immediately to prevent

pulmonary and vascular complications

- Initiate ROM and resisted exercises ASAP to maintain strength and

flexibility of the un operated lower limb and UE

- Begin low intensity, pain free isometrics against gentle resistance to

prevent atrophy of the operated limb

- Begin gentle distal to proximal massage of the operated limb to decrease

post op edema of soft tissues and to decrease hypersensitivity and post
op pain

- Begin AROM or AAROM of the operated hip within a protected range while
the patient is lying supine to maintain soft tissue and joint mobility

- To ensure that bed mobility and transfers are performed safely, review
these techniques to the patient

- When patient is allowed out of bed, usually 2-3 days post op, begin the
following activities:

• Short periods of sitting at edge of bed with hips in no more then 45

degrees of flexion and hips slightly abducted

• Gait training in parallel bars with walker or crutches with PWB on

operated side

Moderate Protection Phase

 - Avoid vigorous stretching but promote heel extension and prevent hip
flexion contracture by having the patient lie prone as tolerated

- If the prosthetic components have been cemented in place and no

trochanteric osteotomy was necessary, exercises in weight bearing, when
tolerated can progress rapidly.

- If trochanteric osteotomy was performed, weight bearing and progression

of exercises will be significantly restricted for at least 6-8 weeks to allow
trochanter to heal

With these considerations in mind,during the period of moderate protection:

- Progress AROM gradually in a protected range, avoid hip flexion past 90

degrees and adduction past neutral

- Emphasize the development of neuromuscular control of hip musculature

rather that strength by means of active and light resisted motions
performed repitively

- Perform movements in an open close kinematic chain. Have the patient

maintain PWB on the operated leg by performing closed chain exercises
standing in the parallel bars or while using walker

Minimal Protection Phase

- Emphasize closed and open chain strengthening and improving endurance

in the hip extensors and abductors when safe

- Use lightweights and high repetitions in a PRE program

- Have the patient make a transition from walker or crutches to cane. May
occur as late as 12 weeks post op

- To improve muscular endurance and general conditioning, have the

patient exercise on a stationary bicycle. Raise the height of the bicycle to
prevent excessive hip flexion

- Avoid high impact recreational activities, such as jumping or restricted

movements that impose heavy rotational forces on the limb

Total Knee Replacement

I. Definition

- Is a surgical procedure in which injured or damaged par of the knee joint

are replaced with artificial parts. The new knee will consist of a metal shell
 on the end of he femur, a metal and plastic trough on the tibia, and if
needed a plastic button in the knee cap.

II. Epidemiology

- TKRs are usually performed in people suffering from severe arthritic

conditions. Most patients who have artificial knees are over the age 55.
Highest rates of utilization were found in Northwest and Midwest, and
lowest were in the East and South. Approximately 65% are females.

III. Etiology

- Severe joint pain with weight bearing or motion that compromises

functional abilities

- Extensive destruction of articular cartilage of the knee due to arthritis

- Gross instability or LOM

- Marked deformity of the knee such as genu varum or valgum

- Failure of a previous surgical procedure

- Significant stiffness

IV. Classifications

Unconstrained Prosthesis

- Can be unicondylar, bicondylar or total condylar

- Can be cruciate retraining, where PCL is spared

- Can be cruciate excising if PCL is no intact

Constrained Prosthesis

- Are hinged or allow no significant accessory motion of the knee, or

partially articulated, semiconstrained replacements that allow a small
degree of varus, valgus or rotation are rarely used today

- Indicated only for patients with severe instability and deformity of the
knee
V. Complications

- Knee pain

- Loosening of prosthesis

- Stiffness

- Metals and plastics may increase risk of infection

- Breakage of components

- Pneumonia, bed sores and confusion

VI. Prognosis

- Almost all patients who undergo TKR report a significant relief of pain with
knee motion and weight bearing. Although patients are encouraged to
achieve full functional ROM of the knee by the time of discharge after
surgery. It may take at least 3 months post op for patients to regain
strength in the quadriceps and hamstring to a pre operative level. About
85-90 of TKR are successful up to ten years. The major long term problem
is loosening. By ten years, possibly 25% of TKE may look loose on xray.

PT Management

I. Assessment

- Determine the amount of pain the patient is experiencing

- Measure the AROM and PROM of the involved extremity

- Check the ROM of all the other joints

- Grade the strength of the affected extremity

- Estimate he strength of the affected joints or extremities as a basis for

post operative ambulation, transfers and ADL’s

- Determine the level of functional independence that the patient had pre
op and the level that he expects post operatively

- Evaluate the gait characteristics, type of assistive device and degree of

weight bearing used during ambulation

II. Treatment and Rationale of Management

Maximum Protection Phase

- Quads and Hams setting exercise, passively coupled with neuromuscular
ES; SLR in supine, prone and sidelying positions to regain neuromuscular
control of the hip and knee musculature while knee is immobilized

- Ankle pumping exercises immediately after surgery ; gentle distal to

proximal massage of the operated LE ; CPM to promote circulation and
decrease post op edema and pain

Weight Bearing

1. Biological Fixation

- Is restricted up to 6 weeks post op and gradually progress over the

duration of rehabilitation. Full weight bearing and ambulation without
assistive devices may not be permissible for up to 12 weeks post op

2. Cement Fixation

- Weight bearing as tolerated is permissible immediately after surgery and

increase to full weight bearing over 6 weeks. Patient should continue to
use crutches or cane through moderate and minimum protection phase of
rehabilitation until adequate strength and stability have returned o the
operated LE.

Moderate Protection Phase

- Exercises to increase strength

• Multiple angle isometrics and light isotonic resistance exercises

of the quads and hams can be added

• Resisted SLR in various positions should be included to increase

strength of hip musculature

• As weigh bearing permits, closed chain mini squats and short

arc lunges to improve stability and functional control of knees

- Exercises to increase ROM

• Gentle self stretching or contract relax exercises are also added

to continue to increase ROM if limited motion persist

• When using a stationary bicycle, the patient may first have the
seat positioned as high as possible

• To increase knee flexion, the seat can be gradually lowered

Minimum Protection and return to activity phase

- By the 12th week after surgery, the emphasis on rehab is on muscle
conditioning so that the patient will have the strength and endurance to
return to full functional activites

- Ambulation activities, stair climbing and so on are gradually increased

- Stationary bicycling and aquatic exercise are excellent non impact

conditioning activites

III. Home and Bedside Instructions

- Positioning to prevent contractures

- AROM t o adjacent joints to maintain ROM

- Ankle pumping exercise to promote circulation

- Relaxation exercises

-
 PHYSICAL THERAPY SECTION
DEPARTMENT OF REHABILITATION MEDICINE
CVGH

SPECIAL TOPIC REPORT: Ortho-surgical Conditions

SUBMITTED TO:
Ms. Avegin Patrice L. Lim
Clinical Instructor

SUBMITTED BY:
Ian James T. Ocampo
VCPTI – ‘11