Surgical protocols

Surgical protocols for the musculoskeletal system vary based on orthopedic surgeon. Below are the most common:

Total hip replacement

• Anterior approach
  • No hip extension past 20 degrees
  • No hip external rotation past 50 degrees
• Posterior approach
  • No hip flexion past 90 degrees
  • No hip internal rotation or adduction past neutral
• General precautions
  • WBAT, with use of assistive device (AD) as needed (crutches, walker)
  • No crossing legs (crossing ankles OK)
  • Use good bending/lifting mechanics (keep back straight and bend at knees)
  • Keep hips above knees when sitting, avoid sitting in deep chairs ROM/Manual Therapy
• Cemented replacement- WBAT
• Non-cemented replacement; TDWB for first 6 weeks

Total knee replacement

• Need at least 90 degrees of flexion to get in/out of car prior to leaving acute care hospital
• Interventions focus on increased knee flexion, quadricep and hamstring strengthening progressing from isometric to concentric
• Cemented- WBAT with AD
• Non-cemented, TDWB with crutches or walker for first 6 weeks

Anterior cruciate ligament (ACL) surgical repair

• Weeks 1-2: Isometrics activities for quads only
  • Brace locked in extension during this time
  • WBAT with use of axillary crutches
• Weeks 2-6: Closed Chain Activities
  • More flexion is allowed (this is MD dependent)
• Weeks 7-8:
  • Graft for ACL is at its most vulnerable for failure
• Week 8:
  • Brace is completely unlocked (can move through full range) ◦ Open chain activities initiated
• Full return to sports is 6-9 months

Posterior cruciate ligament (PCL) repair

• Weeks 1-4: Partial weight bearing (PWB) with crutches
  • Brace locked in extension
  • Interventions: Isometric for quad control, patellar mobilizations
  • Open chain activities with avoidance of posterior translation of tibia on femur
• Weeks 4-6:
  • Weight bearing as tolerated (WBAT) with crutches, brace unlocked for gait in controlled environment only
  • Transition to closed chain activities
• Weeks 6-8: WBAT with crutches, brace unlocked for all activities
  • Closed and open chain activities
• Week 8+: brace discontinued (as allowed by surgeon).
  • Patient may discontinue crutches if they demonstrate the following:
  • No quadriceps lag with SLR o Full knee extension o Knee flexion AROM 90-100 degrees o Normal gait pattern (may use 1 crutch/cane until gait normalized)
  • Balance/proprioception activities

Meniscus repair

• Weeks 1-3: PWB with axillary crutches
  • Braced donned and locked in extension
  • Interventions: Patellar mobilization and quad strengthening starting with isometrics and progressing to concentric
• Weeks 3-6: WBAT with axillary crutches and unlocking of brace
  • Interventions: Focused on increasing 120 degrees of flexion, normal gait, and full extension
• Weeks 6+: WBAT with no brace
  • Strength and balance activities to promote return to prior functional status

Spinal surgeries

• Limiting bending, lifting, and twisting for up to 6 weeks after surgery •Not sitting for more than 30–40 minutes at a time
• Taking frequent short walks every day, gradually increasing distance •Climbing stairs based on comfort level
• Not lifting more than 15 lbs for 12 weeks
• Avoiding extension beyond 10 degrees
• Wear brace as appropriate

Total shoulder arthroplasty

• Weeks 1-3:
  • Neutral rotation, shoulder abduction pillow in 30-45 abduction, no sleeping on surgical side, no lifting, no excessive movements of shoulder
  • Interventions: PROM (pendulum exercises) progressing to AAROM of shoulder flexion only
• Weeks 4-6:
  • Sling remains in place with weaning initiated
  • Interventions: PROM ER and ABD-; AAROM- shoulder flexion, shoulder elevation; strengthening of rotation cuff through isometric activities
• Weeks 7-8:
  • Discontinue sling; no lifting
  • Interventions: Full ROM in all plane; Strengthening rotator cuff
  • Surgical failure most likely at this time when increased strengthening occurs