Rehabilitation After Tibial and Femoral Osteotomy

Clinical Concepts

The protocol described in this chapter was designed for opening-wedge high tibial osteotomy (HTO) and distal femoral osteotomy (DFO). The operative techniques, detailed in Chapter 26 , prevent delayed union or nonunion and collapse at the osteotomy site and allow a rehabilitation program of immediate knee motion and early weight bearing, preventing the complications of arthrofibrosis and patella infera As discussed in Chapter 26 , allograft instead of iliac crest autograft is frequently used in opening-wedge HTO cases. In these knees, a more cautious approach is required for resuming weight bearing because healing is delayed approximately twofold. An iliac crest autograft is still favored in opening-wedge DFO to promote prompt healing because of the larger torques placed across the femoral osteotomy site. Full weight bearing is not allowed until the surgeon advises based on radiographic evidence of healing. In addition, the physical therapist should be informed whether or not a locking plate and screw fixation were used because they provide more rigid fixation. If a smaller non-locking plate and screws were used, protection from weight bearing is required until osteotomy healing is advanced. In rare cases when the opening-wedge has been compromised at the lateral tibial cortex or medial femoral cortex, no weight bearing is allowed until near complete healing of the osteotomy is verified.

Patients receive instructions before surgery regarding the postoperative protocol so they have a thorough understanding of what is expected after the procedure. The supervised rehabilitation program is supplemented with home exercises that are performed daily. The therapist routinely postoperatively examines the patient in the clinic to progress him or her through the protocol in a safe and effective manner. Therapeutic procedures and modalities are used as required to achieve a successful outcome.

The overall goals of the osteotomy and rehabilitation are to control joint pain, swelling, and hemarthrosis; regain normal knee flexion and extension; protect the osteotomy to prevent displacement; resume a normal gait pattern and neuromuscular stability for ambulation; regain lower extremity muscle strength, proprioception, balance, and coordination for desired activities; and achieve the optimal functional outcome based on orthopedic and patient goals.

Immediately after surgery, the lower limb is wrapped with cotton with additional padding placed posteriorly, followed by a double compression and cotton bandage, a postoperative hinged brace, and bilateral ankle-foot compression boots. A commercial ice delivery system is used with the bladder incorporated over the initial cotton wrapping, a few layers from the wound. The neurovascular status is checked immediately in the operating room and carefully monitored in the initial postoperative period. A calf or foot compression system is used for the first 24 hours to promote venous blood flow. Aspirin is prescribed and, rarely in high-risk patients, low-molecular-weight heparin (LMWH) or warfarin sodium. During the first postoperative week, patients are ambulatory for short periods of time but are instructed to elevate the limb, remain home, and not resume usual activities. This program helps address the soft-tissue edema and limb swelling that may occur after surgery.

Prophylaxis for deep venous thrombosis (DVT) includes intermittent compression calf or foot boots on both extremities, immediate knee motion exercises, antiembolism stockings, ankle pumps performed hourly, and aspirin (325 mg 2 ×/day for 10 days). Doppler ultrasound is obtained if a patient demonstrates abnormal calf tenderness, a positive Homans sign, or increased edema.

Important postoperative signs to monitor include ( Table 28-1 ):

• Loss of correction, reoccurrence of varus or valgus malalignment

• Swelling of the knee joint or soft tissues

• Abnormal pain response, increased pain with weight bearing

• Abnormal gait pattern

• Insufficient flexion or extension, limited patellar mobility

• Weakness (strength/control) of the lower extremity

• Insufficient lower extremity flexibility

• Peroneal nerve palsy

• DVT (calf pain, Homans, tibial edema)

• Delayed union or nonunion

Postoperative Rehabilitation Protocol