Surgical protocols

Surgical protocols vary by orthopedic surgeon, but the phases and precautions below reflect common practice. As a PTA, you carry out the plan of care established by the supervising PT - you don’t advance a patient to the next phase or change precautions on your own. Watch for signs a patient isn’t tolerating the current phase (increased effusion, loss of ROM, increased pain with strengthening, or other signs of graft or surgical-site failure) and report them to the supervising PT. For example, if a posterior total hip replacement patient reports crossing their legs or increasing hip pain, stop the aggravating activity and report the finding to the PT rather than adjusting the precautions yourself.

Abbreviations: WBAT = weight bearing as tolerated, PWB = partial weight bearing, NWB = non-weight bearing, FWB = full weight bearing, AD = assistive device, AROM/PROM/AAROM = active/passive/active-assisted range of motion, SLR = straight leg raise, ER/IR/ABD = external/internal rotation/abduction.

Total hip replacement

• Anterior/lateral/anterolateral approach - the anterior capsule is incised during surgery, so extension and external rotation risk pushing the femoral head out the front
  • Limit hip extension and external rotation, avoid combining them, and follow the surgeon’s specific limits: some protocols allow up to 20 degrees of extension and 50 degrees of external rotation, while others keep both at neutral
  • Active abduction may also be restricted early on (lateral/anterolateral approaches) to protect the repaired abductors
• Posterior/posterolateral approach - the posterior capsule is incised, so flexion, internal rotation, and adduction risk pushing the femoral head out the back
  • No hip flexion past 90 degrees
  • No hip internal rotation or adduction past neutral
• General precautions
  • Weight bearing depends on fixation (cemented vs. non-cemented, below), with use of assistive device (AD) as needed (crutches, walker)
  • No crossing legs; whether crossing the ankles is allowed depends on the surgeon’s protocol
  • Use good bending/lifting mechanics (keep back straight and bend at knees)
  • Keep hips above knees when sitting, avoid sitting in deep chairs
  • Interventions: ROM, manual therapy
• Cemented replacement - WBAT
• Non-cemented replacement - PWB 1st 4-6 weeks

Hip arthroscopy for labral repair

• Resisted hip flexion exercises are avoided for the first 4 weeks (per the surgeon’s protocol), and hip flexor tendinopathy is a complication to avoid

Total knee replacement

• Need at least 90 degrees of flexion to get in/out of the car before leaving the acute care hospital
• Total knee replacement is considered when nonsurgical treatments such as medications, injections, physical therapy and walking supports no longer relieve severe pain, stiffness or deformity that limits daily activities
• No pillow under the knee - full knee extension is a priority to prevent a flexion contracture
• Interventions focus on increased knee flexion, quadriceps, and hamstring strengthening, progressing from isometric to concentric
• Cemented - WBAT with AD
• Non-cemented, PWB 1st 4-6 weeks

Post-op complications: stop and report

Watch for these signs after any arthroplasty, ligament, or spinal surgery, and stop the session right away if you see them.

Complication	Signs	PTA action
DVT	Calf pain, swelling, warmth, redness	Stop and notify the PT
Pulmonary embolism	Sudden shortness of breath, chest pain, tachycardia	Medical emergency - activate emergency response
Hip dislocation (posterior approach)	Sudden pain, limb shortened and internally rotated, unable to bear weight	Stop and notify the PT immediately
Surgical site infection	Wound drainage, redness, fever	Stop and notify the PT
New neurological signs (spinal surgery)	New or worsening numbness, weakness, or radiating arm or leg pain; bowel or bladder changes (e.g., unable to urinate); saddle anesthesia	Stop and notify the PT immediately - this can be a hematoma compressing the cord or cauda equina, which needs emergency surgery

Anterior cruciate ligament (ACL) reconstruction

• Graft options: bone-patellar tendon-bone (patellar tendon) or hamstring tendon, each as either:

  • Autograft - tissue harvested from the patient at the time of surgery
  • Allograft - graft material from a tissue bank

• Acute phase weeks 1-2: (patellar autograft only)

  • Brace locked in extension during this time to protect the patellar tendon donor site
  • Knee isometrics
  • Straight leg raises with brace locked in extension
  • WBAT with the use of axillary crutches

• Acute phase weeks 1-2: (all other subtypes)

  • Active knee ROM
  • Knee isometrics
  • Straight leg raises
  • FWB with or without use of axillary crutches

• Criteria before advancing past week 2:

  • Straight leg raise without quadriceps lag or pain
  • Knee ROM of 0 to 90 degrees
  • Minimal pain and effusion

• Subacute weeks 2-6: all types

  • More flexion is allowed
  • Begin stationary bike
  • Closed-chain activities
  • Treadmill walking

• Weeks 7-12:

  • Graft for ACL is at its most vulnerable to failure. Avoid open chain knee extension, focus on hamstring strengthening (delay resisted hamstring work early after a hamstring autograft, since the donor site itself needs to heal)

• Week 12:

  • Open chain activities initiated
  • Jogging permitted

• Full return to sports is 6-9 months, plyometrics allowed

Posterior cruciate ligament (PCL) repair

• Weeks 1-4:
  • Partial weight bearing (PWB) with crutches
  • Brace locked in extension
  • Interventions: Isometrics for quad control, patellar mobilizations
  • Open chain activities with avoidance of posterior translation of the tibia on the femur, since gravity and hamstring pull both stress the healing graft in that direction
  • Knee flexion is limited early because the graft can bear little load (in one review of protocols, to a maximum of 60 degrees for at least the first two weeks)
• Weeks 4-6:
  • Weight bearing as tolerated (WBAT) with crutches, brace unlocked for gait in a 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 the surgeon).
  • Patient may discontinue crutches if they demonstrate the following:
    • No quadriceps lag with SLR
    • Full knee extension
    • Knee flexion AROM 90-100 degrees
    • Normal gait pattern (may use 1 crutch/cane until gait normalized)
  • Interventions: Balance/proprioception activities

Meniscus repair (peripheral meniscus is re-anchored to the joint capsule)

Because this repair re-anchors meniscus tissue to the joint capsule, the tissue needs time to heal - weight bearing and knee flexion stay restricted, with the brace locked in extension early on. Compare this cautious progression to the meniscectomy protocol below, which advances faster because it removes torn tissue rather than repairing it. Pivoting, cutting, deep squatting, and kneeling load the meniscus with compression and rotation, so after a repair they are avoided until the protocol clears them, and low-load stationary cycling is added first.

• Weeks 1-3:

  • NWB with axillary crutches
  • Brace worn and locked in extension
  • Interventions: Patellar mobilization, knee isometrics, resistive open-chain ankle exercises.

• Weeks 3-6:

  • PWB with axillary crutches, brace worn and locked in extension
  • Interventions: Adding straight leg raises in locked brace, supine, prone, and sidelying.

• Weeks 6-8:

  • WBAT with axillary crutches and unlocking of the brace
  • Interventions: Begin AROM exercises to increase knee flexion ROM to 90 degrees.
  • Open chain knee exercises in available range.

• Weeks 8-12:

  • FWB without the brace
  • Interventions: Focused on increasing to 120 degrees of flexion, normal gait, with full extension.
  • Stationary bike to build endurance and ROM
  • Closed chain knee exercises introduced

• Weeks 12+:

  • FWB with no brace
  • Interventions: Progress as tolerated with open and closed chain strength and balance activities to promote return to prior functional status.

Meniscectomy (remove torn portion of the meniscus)

Meniscectomy removes torn tissue rather than repairing it, so there’s no graft or re-anchored tissue to protect - the same interventions used for meniscus repair are compressed into a shorter timeline (about 4-8 weeks), with no brace and earlier weight bearing.

• Week 1: PWB with axillary crutches; AROM exercises to increase knee flexion to 90 degrees; patellar mobilization, knee isometrics, resistive open-chain ankle exercises
• Weeks 2-4: FWB gait; progressing to 120 degrees of flexion with full extension and normal gait; stationary bike for endurance and ROM; open chain knee exercises in available range
• Weeks 5-8: Progress open and closed chain strength and balance activities as tolerated, to return to prior functional status

Medial collateral ligament (MCL) repair

• In the first phase the knee is protected in a hinged brace with passive or assisted range of motion, quadriceps sets, and straight leg raises, and weight bearing is restricted

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
• Wear brace as appropriate
• Stop and report new numbness, weakness, bowel or bladder changes, or saddle anesthesia right away (see the complications table above)

Total shoulder arthroplasty

• Anatomic TSA precaution: limit passive external rotation to about 30 degrees (or the surgeon’s specific limit) for 4-6 weeks to protect the subscapularis repair, and avoid active or resisted internal rotation until cleared
• Reverse TSA precaution: avoid combining shoulder extension, adduction, and internal rotation (for example, reaching behind the back) for about 12 weeks - this combined position is the classic direction of dislocation
• Weeks 1-3:
  • Neutral rotation, shoulder abduction pillow in 30-45 degrees abduction, no sleeping on surgical side, no lifting, no excessive movements of the shoulder
  • Interventions: PROM (pendulum exercises) progressing to AAROM of shoulder flexion only
• Weeks 4-6:
  • Sling remains in place with weaning initiated
  • Interventions: PROM external rotation (within the anatomic TSA limit above) and abduction; AAROM shoulder flexion, shoulder elevation; strengthening of the rotator cuff through isometric activities
• Weeks 7-8:
  • Discontinue sling; no lifting
  • Interventions: Full ROM in all planes as allowed (after reverse TSA, still no combined extension, adduction, and internal rotation until about week 12); strengthening the rotator cuff
  • Surgical failure is most likely at this time when increased strengthening occurs

Distal biceps tendon repair

• Elbow extension is limited at first and advanced gradually (about 5 to 10 degrees a week toward full extension by about six weeks)
• No strengthening starts until about six weeks, so passive stretching into extension beyond the surgeon’s limit is avoided