Surgical protocols

Surgical protocols for the musculoskeletal system vary based on the 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
  • No hip abduction past 30 degrees
• Posterior/Posterolateral/Lateral 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 — PWB 1st 4-6 weeks

Total knee replacement

• Need at least 90 degrees of flexion to get in/out of the car before leaving the acute care hospital
• 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

Anterior cruciate ligament (ACL) surgical repair

• Subtypes of surgical repair: patellar tendon repair, hamstring tendon repair

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

• Acute phase Weeks 1-2: (patellar auto graft only)

  • Brace locked in extension during this time to protect the harvest site of the repaired patellar tendon
  • 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

• Sub acute Weeks 2-6: all types

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

• Weeks 7-12:

  • Graft for ACL is at its most vulnerable to failure. Avoid open chain knee extension, focus on hamstring strengthening

• 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
• 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)
  • Balance/proprioception activities

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

• Weeks 1-3:

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

• Weeks 3-6:

  • PWB with axillary crutches braced, donned, 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 chair 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)

• Weeks 1:

  • PWB with axillary crutches
    • Interventions: begin AROM exercises to increase knee flexion ROM to 90 degrees.
    • Patellar mobilization, knee isometrics, resistive open-chain ankle exercises.

• Weeks 2-4:

  • FWB gait
    • Interventions: Focused on increasing to 120 degrees of flexion, normal gait, with full extension.
  • Stationary bike to build endurance and ROM
  • Open chair knee exercises in available range

• Weeks 5-8:

  • Interventions: Progress as tolerated with open and closed chain 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 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 ER and ABD-; 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; strengthening the rotator cuff
  • Surgical failure is most likely at this time when increased strengthening occurs