Weight bearing Femoral Condyle / Trochlea / Patella

stage 1 – proliferative phase (0-6 weeks)

primary goals

Do not overload the graft site with compression forces
Increase Tibial Femoral and Patella Femoral Mobility
Restore Quadriceps Control
Proximal Hip Girdle Strengthening
Emphasize PROM to tolerance early

brace

  • Hinged brace at 0-40 degrees for 3 weeks and then 0-70 degrees for 3 weeks for a total of 6 weeks controlled motion in brace

weight bearing

  • Begin touch-down immediately up to 30% of body weight with crutches for two weeks and increase by 30% every two weeks up to full weight bearing by 6-8 weeks
  • Bio-feedback with a bathroom scale can be used to help define 30%, 60% and 100% weight bearing.

rom

  • PROM – No AROM (extension) for 6 weeks
  • No Active Extension for 6 weeks – no resistance
  • CPM
    • 6-8 hours per 24 hours – may/may not be broken into 2 hour segments
    • 0-60 degrees for 10 days
    • Then increase by 5 degree increments as tolerated to a goal of 90 degrees by 3 weeks
    • Remove the hinge brace while in CPM
  • Passive Manual ROM by therapist – minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 six weeks, and full ROM by 12 weeks post-op

exercise therapy

  • Quad sets, SLR – include hip flexion, abduction and adduction, and extension
  • Standing resisted isometrics in full extension

physical therapy (the therapist)

  • Gentle multi-directional patella mobilization immediately after surgery
  • Passive Manual PROM by therapist – minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 weeks, and full ROM by 12 weeks post-op – supine position
  • Cryotherapy and Ice Massage for swelling and pain control
  • E-stim for VMO/quadriceps muscle re-education/biofeedback encouraged early after surgery if needed
  • Gentle deep tissue and skin massage/deep friction to hamstring insertions, suprapateller quadriceps, medial/lateral gutters, and infrapatellar fat pad region 2-3 weeks after surgery
  • Whirlpool therapy recommended at 2-3 weeks post-op to enhance motion

comments

  • Avoid active open chain extension or repetitive active knee flexion 40-70 degrees due to increased patella femoral contact forces
  • Contact Physician if ROM not achieved within 20 degrees of goal.
  • No progression of this protocol until cleared by Physician at 6 weeks post-op
  • No leg presses or squats

stage 2 – transitional phase (7-12 weeks)

brace

  • Discontinue Hinge Brace when at 100% weight bearing with good quad control/independent SLR (approximately 8-10 weeks)

gait

  • At 8-10 weeks, patient should be at full weight bearing with/without single crutch or cane

rom

  • Discontinue CPM
  • Gentle Active and Active Assist ROM flexion
  • Progress towards full ROM by 12 weeks

exercise therapy

  • Stationary bicycling without resistance for short intervals (5 min 2-3x/day) as tolerated
  • Strengthening of quadriceps, hamstrings and hip abductors/extensors using elastic band isometrics and closed chain terminal knee extension 0-40 degrees only
  • Pool exercise using kickboard allowed – flutter/straight leg scissor kick only (no whip kick) – straight leg only
  • No open chain strengthening permitted until 9 months after surgery
  • No leg extensions
  • No closed chain leg press or squatting for 6 months – light weights with high repetition

physical therapy (the therapist)

  • Continue gentle multi-directional patella mobilization as needed
  • Continue Manuel PROM by therapist: minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 weeks, and full ROM by 12 weeks post-op
  • Cryotherapy for swelling and pain control
  • E-Stim for VMO/Quadriceps muscle re-education/bio-feedback as needed
  • Gentle massage/deep friction to hamstring insertions, suprapatellar quadriceps, medial/lateral gutters, and infrapatellar fat pad region
  • Whirlpool therapy (if available) to enhance motion

comments

  • Avoid active open chain extension or repetitive active knee flexion 40-70 degrees due to increased patella femoral contact forces
  • Contact Physician if ROM not achieved within 20 degrees of goal.
  • No progression of this protocol until cleared by Physician at 12 weeks post-op
  • No leg presses or squats

stage 3 – remodeling phase (13+ weeks)

brace

  • None

weight bearing

  • Full Weight Bearing

rom

  • Continue full AROM and PROM exercises
  • Progress towards full ROM equal to contra-lateral side

exercise therapy

  • Stationary bicycling with very low resistance as tolerated
  • Treadmill use only after 6 months,
  • Elliptical machine for strength and stamina after 4 months
  • Open chain terminal extension with resistance not permitted and no leg extensions until 9 months
  • Closed chain exercise to promote knee stability and proprioception through full ROM as tolerated
  • Cycling on level surfaces permitted with gradual increase in tension per level of comfort
  • Patient may begin light jogging at 12 months on treadmill, not on concrete

physical therapy (the therapist)

  • Continue multi-directional patella mobilization as needed
  • Pool therapy (if available) to enhance ROM and quadriceps/hamstring muscle control
  • Cryotherapy for swelling and pain control
  • E-Stim for VMO/Quadriceps muscle re-education/bio-feedback as needed
  • Gentle massage/deep friction to hamstring insertions, suprapatellar quadriceps, medial/lateral gutters, and infrapatellar fat pad region

comments

  • Activity level should be modified if increased pain, catching or swelling occurs
  • Bilateral half squats and leg presses with progressive weights after 9 months
  • Unilateral half squats and leg presses after 12 months
  • No pivoting sports should be done until after 12 months
  • May begin light straight line running/jogging after 9 months in pool if available
  • Avoid activity/exercises with excessive patella-femoral compressive forces
  • Swelling is common in patellar implants as much as 9 months after ACI
  • No running or jumping permitted until 12 months after surgery
  • Continued improvement in comfort occurs for 2-3 years before maximal outcome is achieved


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