Tibial Osteotomy eBook

Wellness & Lifestyles Australia

TIBIAL OSTEOTOMY E-BOOK

prepared by Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE .................................................................................................................1 INTRODUCTION ......................................................................................................................2 KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY..........................................................3

Anatomy .................................................................................................................... 3 Degeneration............................................................................................................... 3 Indications for surgery.................................................................................................... 3

PREOPERATIVE ADVICE AND PLANNING ..........................................................................................4 Before the surgery ........................................................................................................ 4 After the surgery .......................................................................................................... 4

OPERATION PROCEDURE............................................................................................................ 5 Tibial Osteotomy: Opening wedge...................................................................................... 5 Tibial Osteotomy: Closing wedge ....................................................................................... 5

ACUTE INPATIENT PHASE (WEEK 1) ...............................................................................................6 Goals......................................................................................................................... 6 What to do.................................................................................................................. 6 What you’ll notice after surgery ........................................................................................ 6 Exercises .................................................................................................................... 7

OUTPATIENT PHASE (UP TO 2-3 MONTHS) ..................................................................................... 11 Hydrotherapy..............................................................................................................13 Stationary bike riding....................................................................................................17 Exercises on land .........................................................................................................17

SUMMARY ........................................................................................................................... 22 CONTACT US ....................................................................................................................... 23

MANUAL LAST MODIFIED 24/02/2011

http://www.wellnesslifestyles.com.au Ph: +61 8 8331 3000 Fax: +61 8 8331 3002

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. © Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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INTRODUCTION Welcome to the W&L series of e-Books. You have chosen the edition on tibial osteotomy rehabilitation. This resource will be beneficial to anyone who: Anyone who is interested in the anatomy and biomechanics of the knee joint Anyone who has knee degeneration problems and is wondering what surgery involves Anyone who is going to have tibial osteotomy and wants to be able to prepare themselves and know

what to expect in advance Anyone who is participating in a tibial osteotomy rehabilitation program and wants a comprehensive

guide to their exercises Anyone who is providing a rehabilitation program and wants up to date information with all the

important details This e-Book will cover information about the anatomy of the knee, provide an explanation about the degenerative process of the knee joint and discuss the alternatives to surgery as well as explaining when it is best to choose surgery. It also will accompany you from the weeks leading up to surgery until you return to your normal routine with advice, answers and exercises. The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.


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KNEE ANATOMY, DEGENERATION AND INDICATIONS FOR SURGERY

Diagram taken from: Ogiela, D. (2009). Normal Knee Anatomy, Medline Plus, accessed 24th January 2011

http://www.nlm.nih.gov/medlineplus/ency/imagepages/8716.htm

Anatomy The tibiofemoral joint is the main joint in the knee and consists of the femur sitting on top of the tibia. The joint surface of the tibia (the shin bone) is relatively flat and has articular cartilage and menisci covering the bone. The femur (thigh bone) is rounded to allow for a rolling movement on the flat tibia and also has articular cartilage. There are large muscles and ligaments surrounding the knee joint to keep the joint secure and transmit weight through the tibiofemoral joint evenly. The knee can be divided into two halves or components. The ‘medial’ component is the inner half of the knee and the ‘lateral’ component is the outer half.

Degeneration Through muscle imbalances in strength or length, trauma, rheumatoid arthritis or general wear and tear the joint surfaces can degenerate. There are many reasons which can cause degeneration but the general process involves the cartilage wearing away and the boney joint surfaces being exposed and rubbing together which can be painful. This type of degeneration is termed “osteoarthritis”. Sometimes the inner (medial) or outer (lateral) compartment of the knee wears before the other so there is osteoarthritis in only one side.

Indications for surgery The main reason for surgery is if the there is a large degree of degeneration in the knee joint which can’t be successfully managed with other treatments such as physiotherapy, medications, weight modification or activity modification. A TKR (total knee replacement) or UKR (unicompartmental knee replacement) will help Reduce pain Increase stability and mobility Improve the knee’s functional abilities Correct alignment or any deformities.


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PREOPERATIVE ADVICE AND PLANNING

Before the surgery Check with your doctor which medications you should be taking in the lead up to your surgery, there

may be some ones you take regularly which you have to stop or some antibiotics you will need to start taking before you have the TKR or UKR.

You may wish to donate some of your own blood for the operation although there is the option to use blood donated for transfusions.

Once you are admitted to hospital you will most likely have to go through a screening examination including x-rays, blood tests, cardiograms and a physical examination.

You will have to fast at least 12 hours before your surgery. During your last shower before the operation, you will have to use a special soap to wash yourself and

give special attention to your knee which is going to have the replacement. There is a choice available for anaesthetic, some will make you unconscious during surgery while

others can be used to numb only your lower half. You will have an opportunity to discuss these options with your anaesthetist and surgeon.

After the surgery You will notice that your knee retains some warmth and swelling for some weeks after your surgery –

this is quite normal. It will gradually subside over time. The early stages of rehabilitation will be crucial for regaining movement in your knee before it fully

heals. Your exercises will cause some discomfort but will not damage your knee. They are important for

regaining function in the long term. You will need some assistance with walking at first (usually using a walking frame or walking stick as

you improve) but will usually be able to walk independently by 6 weeks after surgery. With driving, if you have a TKR or UKR on your left knee and drive an automatic you should be able to

recommence driving immediately. Otherwise, it usually takes about 4 weeks before you will be comfortable enough to drive. Your doctor will advise you when you are clear to drive.

Sexual activity is also appropriate when comfortable. In order to protect yourself and your knee after surgery it is best to avoid Activities with quick movements which may stress your knee through twisting, impacting, kneeling or

stop-starting. Putting a lot of weight through your knee while it is bent (like walking up a steep incline or stairs). Carrying heavy objects or gaining weight. Having to bend down to low chairs or toilets


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OPERATION PROCEDURE

The tibial osteotomy works to either add length to the side of the tibia which has been worn away from degeneration (opening wedge) or take away length from the side which is longer and does not have significant degeneration (closing wedge). The following examples are for when the medial compartment has worn away more than the lateral, as is usually the case.

Tibial Osteotomy: Opening wedge An incision is made to the medial side of the tibia and the edges are widened away from each other so that there is now a wedge opening. The wedge is filled in with either synthetic bone or a bone graft. A bone graft is a section of bone taken from else where in your body, commonly the pelvis. This new wedge of bone is supported by using a plate and screws to hold it in place as it reforms with the rest of your tibia bone. With the opening wedge procedure there may be restrictions as to how much weight can be tolerated through the leg while it is initially healing. Your doctor will provide individualised instructions regarding your weight bearing prescription.

Tibial Osteotomy: Closing wedge In the closing wedge procedure, the lateral side of the tibia is accessed and a wedge of bone is taken out. The size of the wedge is chosen specifically so that when the two edges of the wedge are compressed closer to each other, the knee has an even alignment. The wedge is held in a near closed position with a plate and screws.

Diagram taken from:

Cazenave, A (2007). High Valgus Tibial Osteomy, accessed 25th January 2011 http://www.orthopale.com/tibial‐osteotomy.php


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ACUTE INPATIENT PHASE (WEEK 1) After your surgery you will be given instructions about exercises for rehabilitation. This procedure usually gives excellent improvements in functional ability such as using stairs, driving and all other activities of daily living. This outcome relies on improvements made in the early stages of rehabilitation and diligence with exercises.

Goals The main goals for this first week are to be able to: Fully straighten your knee and bend it past 90° (with the help of your hands) Be able to use your quadriceps muscle to control your knee (see ‘quadriceps control’ exercise) Walk normally with the help of a walking stick or walking frame Be able to do your exercises on your own

What to do Elevate your operated leg with a pillow under your calf to reduce the accumulation of swelling in your

knee. Ice the knee and paddle your feet to help swelling to resolve. Massage your thigh, calf, the sides and back of your knee with moisturising cream. Your leg may be put on a continuous passive movement (CPM) machine which will bend and straighten

your leg for you but try and contribute to the movement yourself. This may be done for 2-3 hours a day.

What you’ll notice after surgery You’ll be monitored regularly for blood pressure, heart rate and temperature as well as movement

and sensation in your operated leg during your hospital stay. You’ll be given T.E.D. (Thrombo Embolic Deterrent) stockings which are used to stop blood clots

forming in your leg while you aren’t using it as much. Keep these on for the six weeks (remove only for washing) or as otherwise instructed. Your T.E.D’s will then be replaced by tubigrip (like an elasticised sleeve), to continue to provide compression support for swelling.

You’ll get out of bed the first day after surgery with assistance from hospital staff, usually with a walking frame, crutches or walking stick.

You will feel tired and walking will be challenging so it is more important to conserve your energy for completing your exercises.

You’ll be in hospital for usually 2 – 4 days. It will take 2 – 3 months for a full recovery so form your expectations with this in mind.


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Exercises These can be started straight after the operation in bed. Ankle pumping: Do 10 every hour.

Repeat the following exercise session twice a day: Quadriceps control: Contract the quadriceps muscle on the top of your thigh to push the back of your knee into the bed. Hold for 5 seconds and repeat 5 times. By placing your hand beneath your knee, you will gain tactile feedback of your hand being “squashed” (as per picture). This will reassure you that you are performing the exercises correctly. Try and maintain this contraction for at least 3 seconds.


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Knee flexion: Use your hands to help slide your heel towards your bottom until you start to feel an increase in pain. Stop and hold this position for 20 seconds and repeat 10 times.

Knee straightening in bed: Rest your ankle on top of a rolled up towel or some other support and relax your knee so that it straightens out fully, hold for 2-3 minutes. Note: It is very important to regain your ability to straighten your knee early on in the rehabilitation. At first, this exercise may cause pain but it won’t cause any damage to your knee.

Inner range quads exercise: Using a rolled up towel under your knee, contract your quadriceps muscle to lift your foot off the bed. Ensure that your leg is straight and you are pushing the back of your knee into the rolled up towel. Gently lower again and repeat 10 times.


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Straight leg raise: With the rolled towel under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Knee bending on chair: While sitting on a chair try to bend your knee as much as possible, using your other foot to help push it under and hold for 20 seconds. Relax your leg and repeat 10 times.


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Knee straightening over chairs: While sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and relax, holding your knee out straight for as long as possible. Aim to build up to 10 minutes at a time. Once again, this exercise will hurt but is very important for a full recovery and won’t damage your knee. Use a distraction like TV or have a conversation to make this exercise easier.

Calf stretch in bed: Sit with your leg outstretched and a band (a belt or towel would be fine) around your foot. Straighten your knee and pull your foot towards you until you feel a stretch and hold for 20 seconds.

Walking: Hold the walking stick in the opposite hand to your operated side. When you place the foot of your operated leg, focus on contracting your quadriceps and buttock

muscles to keep your knee straight. Ensure you place your heel down first when you step, and roll your foot through so you push off with

your toes. Focus on bending your knee when you swing your leg through for the “next step” forwards. Aim to do short walks frequently at first. When you return home, the incidental walks you do around

the house should be sufficient and longer walks aren’t required.


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OUTPATIENT PHASE (UP TO 2-3 MONTHS) This part of rehabilitation is expected to continue for up to 3 months as the knee is still healing and adjusting. For this reason, it is very important to keep working on your exercises and aim to straighten your knee because as time goes on it will be harder to make these changes. Continue to see your physiotherapist, especially if you develop new pains as they will be able to help treat your symptoms. At this stage it is important to keep up Massaging tender areas around you knee. Using ice when your knee becomes hot or has excess swelling, especially after exercise. Elevating the leg when you rest to help reduce swelling. Walk in moderation and be sure to rest when you notice excess heat, swelling or aching. When getting in and out of chairs, try not to rely on hands but focus on contracting your buttock muscles to lift yourself out of the chair. It will help to shuffle to the front of the chair first and lean forward like your nose is approaching your knees.


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When managing steps or stairs, it is important to rely on your buttock muscles to perform the movement and not by pulling yourself with your arms. Early on, the easiest pattern to manage stairs is: good leg first when going up and operated leg first when going down. As you become stronger and more confident you can reverse this pattern so that your operated knee becomes more reliable.


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Hydrotherapy Doing exercises in the water is a great way to strengthen the knee muscles without putting too much pressure through the joint. As well as strengthening the muscles around the knee, it is important to focus on technique and control when doing all your exercises so that your brain has practice in controlling your knee during movements. A hydrotherapy program is started around 2 weeks after the operation. Use this program as a guide but it is recommended to consult your therapist for specific exercises and intensities. Warm up:

Walking forwards, sideways and backwards, 2 laps each. By the edge of the pool to hold on: Marching on the spot, 20 steps

Bringing your heel to your bottom, 20 times


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Forward and backward pendular swings (floating your leg up in front of you and then swinging it in a

backward direction as far as you can manage) 20 times

Sideward leg swings (lift your leg out to the side whilst trying to keep your trunk still) 20 times

Squats, 10 times (do this exercise on one leg when you gain strength and confidence)


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By the steps: Step up leading with operated leg and step down leading with non operated leg (this is the opposite to

the stepping order on land), 20 steps


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With a floating cuff: Attach the floating cuff to your operated foot to assist with these stretches Resisted knee extension: stand tall and allow the knee of your operated leg to float behind you until

you feel a stretch in the front of your thigh. Concentrate on pulling your foot back down to the pool floor,, keeping your knee straight. Alternatively, start with your operated leg out in front of you, and attempt to bend it back behind you (as per picture). In both cases the float works to provide resistance to your movement.

Hamstring stretch: with your back against the wall, hold onto the rails, stand tall and allow the cuff to raise your operated leg straight in front of you while keeping your knee and trunk straight. Feel the stretch at the back of your thigh or in your knee and hold for 30 seconds and repeat twice more (there is no need to hold the leg when using the float). Then concentrate on pulling your foot back down to the pool floor.

Cool down: Walking forwards, sideways and backwards, 2 laps each.


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Stationary bike riding Bike riding is a safe way to stretch your knee and increase the amount it is able to bend. Begin with the seat adjusted up high and no resistance on the wheel. Try to push the pedals and complete a full cycle, if you can do the full cycle then lower the seat so

that you are unable to complete a cycle. Push the pedals so that your operated knee is bent and you can feel like it cannot bend any further,

holding the stretch for 20 seconds. Push the pedals backwards to release the stretch and then repeat 5 times. General pedalling will also help the smoothness of movement of your knee and strength in the muscles

– be sure to let the operated leg drive the pedalling. For the stretches, the non-operated leg may be the controlling leg.

Exercises on land Repeat this program daily: Knee straightening over chairs: Perform this exercise the same as you did in the acute phase. While sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and relax, holding your knee out straight for as long as possible.


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Straight leg raise: Perform this exercise the same as you did in the acute phase. With the rolled towel under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Standing: While standing focus on holding yourself tall with symmetry. Keep feet parallel, contract your quadriceps and buttock muscles to control your lower half and raise your chest to make yourself tall. Hold this posture for 2 minutes, especially after you’ve been sitting down for a while.


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Calf stretch over step: While holding onto a surface (such as a kitchen bench), have the balls of your feet on a step or phonebook and your big toes together. Drop your heels down, keep your knees straight and tuck in your bottom so that you feel a stretch in your calves. Hold this for 30 seconds and repeat 3 times.

Knee bending on the edge of a chair: While sitting on a chair tuck your feet under the chair. Shuffle forward on the chair until you feel an increase in pain in your knee and hold for 30 seconds. Relax your leg and repeat 10 times.


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Knee bending stepping on a chair: Step your foot onto a chair and lean forward so that you bend your knee and feel a stretch. Hold for 30 seconds, lean back to release the stretch and repeat 10 times.

Quadriceps stretch on your tummy: Lying on your tummy have a band hooked around your operated leg and over the shoulder opposite to your operated side (e.g. left foot and held over your right shoulder) and pull so that you feel a stretch at the front of your thigh. Hold for 30 seconds and repeat 3 times.


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Balancing on one leg: Standing while holding onto supports (for example, chairs either side) shift your weight over to your operated leg and lift your good leg up. When you feel confident, lift your hands one at a time and count how long you can hold it. Continue daily until you can hold your balance for more than 20 seconds.

Weight transfer in lunge: Stand with your operated leg in front and knee slightly bent, put most of your weight through your operated leg. Check that your hips and shoulders aren’t twisted or tilted and that your belly button is directly in line with your big toe. Hold this position for 5 seconds and then step forward with your good leg. Repeat this step 5 times to form a new walking pattern.


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SUMMARY In summary, degeneration of the knee joint can occur for many reasons and can be sometimes predominantly in one side of the knee. A tibial osteotomy can be performed as a way of achieving better alignment in your knee and reduce the rate of degeneration. This will prolong the time before a total knee replacement is required. Early rehabilitation will be important for gaining full function back in the knee. Although there is some pain with exercise, this is not dangerous for your joint. The more you push yourself in your rehabilitation the better your long term functioning will be. A full recovery is expected in 2 – 3 months after surgery. You can then expect to resume your normal activities with less pain, stiffness and general restriction from your knee. Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist.

All the best for a speedy recovery,

The W&L Team.


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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 08 8331 3000 F: +61 08 8331 3002 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules

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Tibial Osteotomy eBook