Surgical Interventions and Postoperative Management

Indications for Surgical Intervention

⚫ Many acute, recurring, and chronic musculoskeletal conditions are managed successfully with
conservative measures.
⚫ However, surgical intervention is the best treatment option when:
1. A conservative program has not been successful in adequately
modifying impairments or restoring function.
2. The severity of a patient’s condition is beyond the level that is
appropriate for conservative management.
⚫ A carefully planned and progressed rehabilitation program is essential
for the patient to achieve optimal functional outcomes after surgery
1. Before surgery: (1) patient education, (2) pre-habilitation exercise (3) functional skill development.
2. After surgery: (1) direct intervention from therapist, (2) long-term self management by the patient.
Considerations for Preoperative Management
⚫ The benefit of preoperative communication and instruction with a patient include:
1. Assess their preoperative functional status.
2. Discuss their goals and expectations following surgery.
3. Establish rapport (醫病關係).
4. Educate the patient regarding postoperative rehabilitation.
⚫ Preoperative examination and evaluation
1. Identify the patient’s needs and goals, document the pre-surgical level of function, and generate a
prognosis regarding the expected functional outcomes following surgery.
2. Examination of specific factors is important for developing realistic goals and estimating
functionally relevant outcomes of surgery and postoperative rehabilitation.
⚫ Preoperative patient education
1. Forms: one-to-one, group, team members.
2. Programs such as these may help a patient understand what to do in surgery, and during the early
postoperative phase, possibly alleviating some of a patient’s anxiety about the surgery.
3. Components of preoperative patient education:
 Overview of the plane of care
 Postoperative precautions
 Bed mobility and transfers
 Initial postoperative exercise: (1) deep-breathing, (2) cough exercise, (3) ankle pumping, (4)
muscle setting exercise of immobilized joint.
 Gait training: teach patient to use supportive devices.
 Wound care
 Pain management: educate on the correct use of cryotherapy.
⚫ An extended preoperative exercise program (長期的術前運動)
1. The rationale for implementing an exercise program prior to a planned surgical procedure:
 To limit further progression of impairments.
 To improve the likelihood that learning will carry over and exercises will performed correctly
following surgery.
  To increase the likelihood of achieving optimal postoperative functional outcomes.
2. A preoperative exercise program may be beneficial if a prolonged period of immobilization or
reduced weight bearing is necessary after surgery.
Considerations for Postoperative Management
⚫ Factors that influence components, progression, and outcomes of a postoperative rehabilitation program

⚫ Postoperative examination and evaluation

1. In addition to the components of a preoperative examination noted previously, an assessment of
integumentary integrity is important after surgery.
2. The incision should be inspected before and after each exercise session.
⚫ Phases of postoperative rehabilitation
1. Phases can be distinguished in several ways:
 By sequences of tissue healing (acute/inflammatory, subacute/proliferative, chronic/remodeling).
 By the permitted level activity (initial, intermediate, advanced).
 By the degree of protection of healing tissues (maximum, moderate, minimum protection).
 By sequential numbering.
2. In general, the goals and intervention across the phases of postoperative rehabilitation:
Minimizing pain
Early after surgery Preventing postoperative complications
Resuming a safe level of functional mobility
Restoring or improving ROM, strength, neuromuscular control, endurance
Later after surgery
Functional activities.
3. The key to successful postoperative outcomes is effective, long-term patient self-management.
 This approach includes therapist-directed, early postoperative patient education, followed by a
home program of selected interventions.
 In particular, a progression of exercises that have been carefully taught and are periodically
monitored and modified by the therapist during each phase of rehabilitation.
⚫ Management guidelines
Maximum protection phase
1. This is the initial postoperative period when protection of operated tissue is in the presence of tissue
 inflammation and pain.
2. Time frame ranges from few days to 6 weeks depending on type of surgery and the tissue involved.
Moderate protection phase
1. Inflammation has subsides, pain and tenderness are minimal, and tissue are able to withstand
gradually increasing levels of stress.
2. Criteria for progression to this phase often include (1) the absence of pain at rest, (2) availability of
at least limited pain-free movement of the operated extremity.
3. Depending on the healing characteristics of the operated tissues, this phase typically begins around
4 to 6 weeks postoperatively and continues for an additional 4 to 6 weeks.
Minimum protection phase
1. To progress to this phase, full (or almost full) pain-free active ROM should be available and the
joint capsule should be clinically stable.
2. This phase begins anywhere from 6 to 12 weeks postoperatively and may continues until 6 months
postoperatively or beyond.
⚫ Potential postoperative complications and risk reduction

1. Pulmonary complications
 The risk of pneumonia (肺炎) or atelectasis (肺擴張不全) is highest during the early
postoperative period.
 General anesthesia and use of pain medication increase the risk of these complications, as does
extended confinement to bed.
 Deep breathing exercise initiated on the day of surgery and early standing and ambulation
following surgery may reduce this risk.
2. Deep vein thrombosis (DVT) and pulmonary embolism
3. Failure, displacement or loosening of internal fixation device
 Excessive weight bearing may cause loss of bone-to bone apposition of the fracture site.
 Heavy lifting or strong muscle recruitment after a soft tissue repair in the upper extremity can
cause rupture of sutured, but incompletely healed, tissues.
 Proper use of supportive devices to control weight bearing during ambulation and appropriate
progression of exercise and functional activities.
4. Joint subluxation or dislocation
 If a joint capsule being incised during surgery for total joint replacement or open labrum repair,
there is an increased risk of postoperative joint dislocation.
 This risk can be reduced through patient education and exercise instruction.
5. Restricted motion from adhesions and scar tissue formation
  Postoperative contractures can develop as incised or repaired tissue through the healing process.
 Reducing by ROM exercises or continuous passive motion (CPM) with a safe range.
A Closer Look: Deep Venous Thrombosis and Pulmonary Embolism
⚫ Introduction
1. A thrombosis is a bolus of coagulated blood in the circulatory system.
 Thrombus in superficial veins (calf) usually is small and resolves without serios consequences.
 In deep vein in the calf, thigh or pelvis region, known as DVT, tends to cause serios complications.
 When a clot breaks away from the wall of vein and travels proximally, it is called an embolus.
 When an embolus affects pulmonary circulation, it is called a pulmonary embolism, which is a
potentially life-threatening disorder.
 The risk of development of DVT is increased after total joint replacement surgery (TKR, THR).
⚫ Risk factors for DVT

⚫ DVT: signs and symptoms

1. Early stages of a DVT, only 25% to 50% of cases can be recognized by clinical manifestations, such
as dull aching or severe pain, swelling, or skin heat and redness.
2. The Wells Criteria provide the clinician with a tool to establish the likelihood of a lower extremity
DVT when the condition is suspected.
3. When a DVT is likely based on the clinical features present, medical testing should be initiated
should be confirm or rule out the condition.
4. Only diagnostic imaging, such as ultrasonography, venous duplex screening, or venography, can
confirm a DVT.
⚫ Pulmonary embolism: sign and symptoms
1. Signs and symptoms depending on the size of the embolus, the extent of lung involvement, and the
presence of coexisting cardiopulmonary conditions.
2. Hallmark signs and symptoms
 A sudden onset of shortness of breath (dyspnea).
 Rapid and shallow breathing (tachypnea).
 Chest pain located at lateral aspect of the chest that intensifies with deep breathing an coughing.
3. Other signs and symptoms include: swelling in the LE, anxiety, fever, excessive sweating, a cough,
hemoptysis.
4. If patient present with signs or symptoms, immediate medical referral.
⚫ Reducing the risk of DVT
1. Prophylactic use of anticoagulant therapy for the high-risk patient.
 2. Elevating the legs when lying or when sitting.
3. No prolonged periods of sitting.
4. Initiating ambulation after surgery as soon, preferably no more than a day or two postoperatively.
5. Active ankle pumping exercise regularly throughout the day when lying supine.
6. Use compression stockings and sequential pneumatic compression unit.

⚫ Management of DVT
Acute management
1. Immediate medical intervention is essential to reduce the risk of pulmonary embolism.
2. With anticoagulant medication, placing the patient on bed rest, elevating the extremity, and using
compression stockings.
3. The report time frame for bed rest varies from 2 days to more than a week.
4. During the period of bed rest, exercise usually are contraindication.
5. Ambulation can begin after anticoagulant therapy reaches therapeutic levels.
Posthospitalization precautions
1. Following discharge, a patient typically continues on an anticoagulant medication for about 6
months.
2. Patient must avoid contact sports, running, and skiing; however, treadmill walking or jogging is
permitted.
Overview of Common Orthopedic Surgeries and Postoperative Management
⚫ Repair, reattachment, reconstruction, stabilization or transfer of soft tissues
Muscle repair
1. 通常會等急性期過去(減輕)後才會進行手術治療，特稱為 late repair (approximately 48 to 72
hours after injury)
2. For repair, the muscle is re-opposed, sutured, and immobilized in a shortened position as healing
begins.
3. Postoperative management
 Gradual muscle setting exercise initiated immediately after surgery.
→ 在肌肉固定期間，應該執行 submaximal muscle setting
 Active ROM (within a protected range) to prevent contractures and restore joint mobility.
 Low-load, high-repetition resistance exercise should not elicit pain and be progressed gradually.
 Weight bearing is restricted until the patient achieves a functional level of strength and flexibility.
 Vigorous stretching or the return to full actively level are contraindicated until soft tissue healing
is complete – as long as 6 to 8 weeks postoperatively.
Tendon repair
1. A complete tear or laceration of a tendon should be repaired immediately or within a few days
after injury.
→ To prevent tendon retract, making reattachment difficult.
2. After the tendon is sutured, the repaired muscle-tendon unit is maintained in a shortened position.
3. A longer immobilization period than muscle repair, because of poor vascular supply to tendon.
4. Postoperative management
 Muscle setting immediately after surgery.
 Passive motion or active contraction of a muscle group that is an antagonist of the repaired
tendon within a protected range.
 Controlled antigravity motions are initiated after repaired tendon has had several weeks to heal.
 Weight bearing may be restricted after an upper or lower extremity tendon repair, and heavy
lifting activities are often contraindicated for as long as 6 to 8 weeks.
 Vigorous stretching and high-intensity resistance exercise should not be initiated at least 8 weeks
after repair.
Ligament repair or reconstruction
1. There are many surgical procedures that involve ligamentous repair or reconstruction.
 Open or arthroscopically assisted procedures.
 Autograft, allograft, or synthetic grafts.
2. Postoperatively the joint is held in a position to a safe level of tension during healing process.
3. The duration of immobilization various with the site and severity of injury and the type of repair
or reconstruction that was done.
4. Postoperative management
 Rehabilitation after ligament surgery emphasizes early but protected motion and progressive
strengthening and weight bearing activities to load the healing tissues consistently but safely.
 The rate of progression depends on many factors.
 Generally, postoperative rehabilitation after ligamentous surgery is a lengthen process.
 For patients return to high-demand work or sports activities it may take at least 6 months or as
long as a year of rehabilitation .
Capsule stabilization and reconstruction
1. This type of surgery is indicated for a patient with:
 Traumatic dislocation with associated capsular or labral avulsion or fracture.
 Recurrent dislocation or symptomatic subluxation despite a course of nonoperative treatment.
 An irreducible (fixed) dislocation.
 2. Capsule stabilization or reconstruction procedures include capsulorrhaphy (capsular shift),
capsulolabral reconstruction, or electrothermally assisted capsulorrhaphy.
3. Postoperative management
 Restore the balance among joint stability and functional motion while protecting the joint capsule
and other repaired tissues during healing process.
 The duration of the immobilization period and the selection and progression of postoperative
exercise and functional activities depend on factors such as:
A. Preoperative sirection of the instability.
B. Surgical approach
C. Type of stabilization or reconstruction procedure and tissue fixation.
D. Quality of the patient’s tissue.
 Postoperative exercise focus on : restoring ROM, active motion, strengthening exercise (dynamic
joint stabilizers).
Tendon transfer or realignment
1. The transfer or realignment of muscle-tendon unit alters the line of pull, potential force generation,
and excursion of the muscle.
2. Transfers may be indicated, for example:
 To improve the stability of an unstable shoulder joint.
 To stabilize a chronically dislocating patella.
 To prevent deformity and improve functional control for the patient with a neurological deficit.
3. During a typical tendon transfer procedure, the distal attachment is removed from its bony insertion
and reattached to a different bone.
4. The realigned muscle-tendon unit is then immobilized in a shortened position for a period of time.
5. Postoperative management
 As with tendon repair, early muscle setting and protected motion to maintain tendon gliding.
 Resisted movements are progressed cautiously and gradually to protect the reattached tendon.
 Biofeedback and electrical muscle stimulation are often used to help a patient reeducate muscle.
⚫ Release, lengthening, or decompression of soft tissues
1. Soft tissues may be incised or sectioned to improve ROM, prevent or minimize progressive
deformity, or pain.
2. Procedure include myotomy, tenotomy, or fasciotomy.
3. The incised (release or lengthening) structures are then immobilized in a lengthened position.
4. The decompression procedures, fasciae may be released or removed.
5. Postoperative management
 CPM and/or active-assistive ROM is initiated within a day or two after surgery.
 As soft tissue healing progress, this is followed by active ROM through the gained ranges.
 Strengthening of the antagonists of the lengthened muscle and functional use within the available
ROM are also started early to maintain active control of movement within the newly gained range.
⚫ Joint procedures
Arthroscopic debridement and lavage
1. Involve arthroscopic removal of fibrillated cartilage, unstable chondral flaps, and fragments of
cartilage or bone from a joint.
2. The procedure is most often indicated to relieve joint pain and clicking, ratcheting, or catching
during joint movement.
Synovectomy
1. Removal of the synovial lining of the joint in the presence of chronic joint inflammation.
2. Temporarily relieves pain and swelling and is thought to protect articular cartilage or tendons from
enzymatic damage secondary to the tenosynovitis.
3. Postoperative management
 Arthroscopic approach
A. Passive or assisted ROM exercise and muscle setting exercise are begun immediately or
within 24 hours after surgery.
B. Synovectomy of the knee partial weight bearing as tolerated during ambulation progresses
to full weight bearing by 10 to 14 days.
C. Wrist or elbow synovectomy, lifting heavy objects is restricted for several weeks.
D. Every effort should be made to avoid excessive exercise or activity that could increase joint
pain or swelling.
 Open synovectomy, progression of exercise and ADLs proceeds more slowly than after
arthroscopic synovectomy.
Articular cartilage procedures
1. Rehabilitation after all of the articular cartilage procedures, with the exception of arthoscopic
debridement, is a slow and arduous process.
2. A well-controlled program of progressive exercise continues for 6 months to a year to achieve
optimal functional outcomes.
Arthroplasty
1. Any reconstructive joint procedure designed to relieve pain and improve function is referred to
broadly as arthroplasty.
2. This definition encompasses excision, interposition, and replacement arthroplasty, procedures that
may or may not include a joint implant.
Arthrodesis
1. Arthrodesis is surgical fusion of the joint surface for
 Severe joint pain associated with late-stage arthritis.
 Significant weakness of muscles surrounding a joint as the result of neurological abnormalities.
 Salvage procedure for a patient with a failed total joint arthroplasty.
2. Fusion of joint surfaces in the position of maximum function is achieved with internal fixation.
 3. Postoperative management
 Initially, the joint is immobilized in a cast for 6 to 12 weeks postoperatively.
 Later, an orthotic device is used until complete bony healing and joint ankylosis has occurred.
 Because no movement is possible in the fused joint, ROM and strength must be maintained above
and below the operated joint.
 Weight bearing is restricted until there is evidence of bony healing.
4. There is an potential that excessive stress may lead to pain and hypermobility at compensate joint
over time.
⚫ Extra-articular bony procedures
Open reduction and internal fixation of fractures
Osteotomy
1. Osteotomy – the surgical cutting and realignment of bone – is used to reduce pain and correct
deformity and leg length discrepancy.
2. After the osteotomy, the surgeon may apply external fixation or insert internal fixation.
3. As with any type of soft tissue repair, muscle-tendon units disturbed during surgery must be
protected from excessive stress postoperatively.
4. Postoperative management
 Allowing early joint motion and protected weight bearing because internal fixation maintains
apposition of the osteotomy fragments.
 If cast stabilization is necessary, the patient can begin active ROM of the joints above and below
the site of the osteotomy to prevent joint stiffness and muscle weakness.
 Weight bearing is typically protected for 4 to 6 weeks or more.
 Full functional recovery after osteotomy may take as long as 6 months.