Post-Surgical Protocols

Open Shoulder Stabilisation

There are three phases to your rehabilitation programme following your surgery. When you start, each phase is dependent upon your surgeon. The exercises should be done 5 times a day to the point of stretch pain. Each exercise should be repeated 10 times.

STAGE 1 - Passive Assisted (Your good arm does most of the work)
  1. Lying on your back, grasp the wrist of your sore arm with your good hand. Letting the good arm do all the work, lift your sore arm straight up and over your head as far as you can. Slowly lower it by your side. Remember to relax your sore arm and let the good arm do all the work. Progress this exercise by doing it with sitting or standing.
  2. Lying on your back, bend your elbows to 90 degrees and tuck them into your sides. Hold onto a cane (or dowling/broomstick 20" long) and use your good arm to push the sore forearm away from your body. Remember to keep your elbows at your side and bent to 90 degrees. Progress this exercise by doing it with sitting or standing. Do not exceed 20 degrees of external rotation.
  3. Standing, hold a cane (or dowling/broomstick) behind your back with both hands. Lift your arms away from your back. Keep your elbows straight and do not bend at the wrist.
  4. With your hands behind your back, grasp the wrist of your sore arm with your good hand. Gently pull your sore arm up the middle of your back, bending both elbows.

Note: Pendulum exercises may be added as a warm up exercise. Standing, bend over from the waist with your good hand holding on to the back of a chair and your sore arm hanging loosely in front of you. Do the following exercises:

  1. Gently swing your sore arm forward and backward, holding your thumb in the following three positions - towards your body, thumbs straight ahead and thumbs away from your body
  2. Gently swing your sore arm in circles (both directions) with your thumb in the three directions as above.
STAGE 2A – Active with End Range Stretch (Your sore arm does all the work with a gentle push from the good arm at the end of the range)
  1. Lying on your back, raise your sore arm straight up and over your head as far as you can. Give it a gentle push with your good hand to the point of pain, hold for 5 seconds and return to starting position without help. Progress this exercise by doing it sitting or standing as pain permits.
  2. Lying on your back, bend the elbow of your sore arm to 90 degrees and tuck it into your side. Throughout the exercise move your sore forearm away from your side as far as you can. Give it a gentle push with your good hand to the point of pain. Progress this exercise by doing it in sitting or standing. Remember to keep your elbows tucked into your sides throughout the exercise.
  3. Standing, reach as far up as the middle of your back with your sore arm, as you can. Use a towel over your shoulder to pull the sore arm up your back with the good arm until you feel a good stretch.
STAGE 2B (When instructed by your surgeon you may add the following strengthening exercises with Theraband to your active end range stretching exercises)
  1. With both your elbows held comfortably at your sides and bent to 90 degrees, put the Theraband around your wrists. Move both wrists away from your sides, then slowly relax controlling your movement.
  2. Attach Theraband to a door knob. Bend the elbow at your sore arm to 90 degrees and hold it comfortably at your side. Grasp the Theraband and pull your sore arm across your body, then slowly relax, controlling your movement.
  3. Attach Theraband to a door knob. Stand with your back to the door. Bend the elbow of your sore arm to 90 degrees and pull the Theraband straight in front of you, then slowly relax, controlling your movement.
STAGE 3 – Terminal Stretch
  1. Stand in a doorway and reach up to the top of the door frame. Step forward until you feel a good stretch. Hold for 5 seconds.
  2. Stand in a doorway with your involved arm held between the door frame and your body with your elbow bend at 90 degrees. Use your good hand to push your sore arm out as far as you can, ensuring that you feel a good stretch. Hold for 5 seconds.
  3. Standing, reach behind your back with your sore arm. Use a towel over your shoulder to pull the sore arm up your back with your good arm until you feel a good stretch. Hold for 5 seconds.

Continue with the strengthening exercises as in Stage 2B

Exertional Compartment Syndrome

Your lower leg is divided into 4 compartments by partitions between the two bones . The muscles within these compartments are surrounded by tissue known as fascia. When you exercise, blood flow to your muscles increases and your muscles swell. In exertional compartment syndrome, the fascia is too tight to allow this swelling and the muscles become swollen to the point where the blood flow becomes interrupted. The lack of blood flow causes the muscles to become starved of oxygen and this causes pain. Stopping the exercise leads to a decrease in the pressure within the compartments, allowing the blood flow to resume and the pain usually goes away quickly. Sometimes the pain will respond to activity modification, physiotherapy and shoe wear adjustments. Sometimes no matter what you do the pain does not go away and if this is the case, surgery to increase the volume of the compartment by splitting the fascia becomes an option.

Exertional1
The Operation - Fasciotomy ( Release of the tight fascia )

Fasciotomy involves making incisions over the tight compartments in the leg in order to release the tight fascia enclosing the muscles. The incisions vary in length and number depending on the surgeon’s preference and which compartments need releasing. Releasing the fascia usually means that the muscles will now have adequate room to swell when you exercise. Most fasciotomy surgery will require you to stay in hospital for one night. You will be given a time and a date for your surgery along with any special instructions. Both the surgeon and the anaesthetist will see you before the operation. They will explain the procedure and ask you to sign a consent form. You should confirm what leg is to be operated on (fasciotomy surgery usually involves both legs but not always). You should also ask for more information if you wish. At the end of the procedure the wounds are usually injected with local anaesthetic to help with pain relief. A small drain is placed to collect bleeding – this will be removed before you leave hospital. Finally a padded bandage is applied over dressings to seal off the wounds.

Exertional2

The incision is made between the 2 marks on the leg as seen above and is usually between 8-10cm long.

Exertional3
After the Operation

You will remain in hospital overnight with your legs elevated. Most people will go home the next day once the drains are removed. Although you will be able to walk after the operation you will be given crutches and advised to spend as little time on your feet as possible. This is especially important in the first week following surgery to decrease the chances of the legs swelling and causing problems with healing of the wounds. The bandages are left on until you are seen in clinic usually 7-10 days after the operation. If you wish to shower or bathe, tape a plastic bag over your knees to stop the wounds getting wet.

When the anaesthetic wears off you should expect some pain in the legs but this should not be severe. If you experience pain you should take the tablets provided and elevate the legs. If the bandage feels too tight it can be taken off and reapplied more loosely.

If you have a sedentary job and the wounds are healing nicely you may return to work after 10-14 days. If your job involves heavy manual labour you should wait to receive clearance from your surgeon. You should be able to drive a car when you have full control of your legs and your wounds are healed.

When you leave the hospital you should have an appointment card with a time for your follow-up check at the clinic. If not, telephone to make an appointment.

Complications

Possible complications of fasciotomy include anaesthetic complications, wound healing problems arising from infection or bleeding which can in turn lead to unsightly scarring. Deep vein thrombosis ( DVT ) or blood clots in the calves is also a risk and it is possible that you may have some numbness around the wounds or on the foot but this usually becomes less noticeable with time. There is also a small chance that the surgery does not relieve all of your symptoms.

At your first clinic follow up appointment you will be advised to place a hypoallergenic paper tape on your wounds to help minimize scarring.

Knee Arthroscopy

Arthroscopy or ‘keyhole surgery’ of the knee involves making an incision, approximately 1cm over the front of the knee in order to examine the internal structures using a camera. Additional incisions may be made to allow the introduction of instruments to treat a wide variety of conditions affecting the knee.

The Operation

Knee arthroscopy is usually performed as a day case procedure. You will be given a time and date for your surgery along with any special instructions. Please ensure that you bring any x-rays or scans to the hospital on the morning of the operation. Both the surgeon and anaesthetist will see you before the operation. They will explain the procedure and ask you to sign a consent form. You should confirm which knee is to be operated on and take the opportunity to ask for more information if you wish. At the end of your operation the knee will be filled with local anaesthetic to help with pain relief.

After the Operation

Your knee will be bandaged before you go home. You should leave the bandage on for 48 hours. If you wish to take a shower, tape a plastic bag over the knee. After 48 hours you can bath or shower normally. Let the adhesive strips peel off the puncture sites. Usually the puncture sites are dry by 48 hours following arthroscopy. Occasionally the puncture sites may leak, in which case you can use a band-aid to cover this.

When the anaesthetic wears off you should expect some pain in the knee but this should not be severe. If you experience pain you should use the tablets provided and elevate the leg. Applying an ice pack to the knee may also be helpful. Some swelling is to be expected and it may actually increase gradually for the first 2-3 days. If the bandage feels too tight please re-wrap it.

If you have a sedentary job you may return to work when you can walk unaided with reasonable comfort. You should be able to drive a car at this time but must have full control of your leg. If your job involves heavy manual work you should wait until you receive clearance at the follow-up check.

When you leave the hospital you should have an appointment card with a time for your follow-up check at the clinic. If not, telephone to make an appointment.

Complications

Although the risks of arthroscopy are minimal no procedure is entirely risk-free. Possible complications of arthroscopy include anaesthetic complications, wound and joint infections and deep venous thrombosis (DVT) or blood clots in the calves. It is possible to have some numbness around the scars but this usually becomes less noticeable with time.

You will be able to walk when you go home but you should plan to rest up for the first 48 hours. During this time you should concentrate on working on the movement of the knee rather than walking or standing for long periods. After 48 hours you can increase your activity according to how the knee feels.

ACL Reconstruction

The knee is a modified hinge joint between the end of the femur (thigh bone) and the top of the tibia (shin bone). There are four main ligaments connecting these two bones.

Acl

The medial and lateral collateral ligaments (MCL / LCL) run along the inner and outer parts of the knee respectively and prevent the knee from bending outward and inward.

The anterior cruciate ligament (ACL) lies in the middle of the knee. Its function is to stop the tibia from sliding out in front of the femur. It also provides rotational stability to the knee. The posterior cruciate ligament (PCL) which is not labelled in the diagram prevents the tibia from sliding backwards under the femur. These two ligaments cross each other inside the knee forming an "X.". This is why they are called “cruciate” (cross-like) ligaments.

The Injury

When an ACL injury occurs, the knee becomes less stable. This can be a problem because this instability can make sudden, pivoting movements difficult. Many patients are able to compensate for an ACL injury by either modifying their recreational activities or strengthening the knee, however, in some individuals, particularly in high demand sports, recurrent instability or 'giving way' can occur. This may make it impossible for the individual to take part in these types of activity. In addition recurrent episodes of instability can cause damage to the joint surfaces of the knee or the knee cartilages (menisci) and make patients more prone to developing arthritis.

ACL Reconstruction

Once it has been ruptured the ACL is unable to heal. It is possible in selected patients to stabilise the knee by performing an operation to reconstruct the ligament. This procedure does not however make the knee normal and may result in some initial stiffness and discomfort. A new ACL can be ‘made’ using either tendons taken from the hamstrings behind the knee or from the patellar tendon at the front of the knee. The choice of graft is dictated by a number of factors that will be assessed by your surgeon and may be discussed during the preoperative consultation.

In addition to undertaking cruciate ligament reconstruction your surgeon will perform a thorough arthroscopic (keyhole) examination of the knee to assess the cartilages and joint surfaces for any evidence of damage. Injured structures will be treated by either repairing or removing the damaged parts as appropriate.

Although the risks of surgery are minimised wherever possible, no procedure is entirely risk-free. Possible complications of surgical reconstruction of the ACL include anaesthetic complications, wound infections and deep venous thrombosis (DVT) or blood clots in the calves. It is common to have some numbness around the scar which usually becomes less noticeable with time. Stiffness and pain in the knee can occur following surgery but are unlikely if rehabilitation protocols are followed. Rupture of the ACL graft can occur but this is a rare occurrence.

The Operation

You will be given a time and date for your surgery along with any special instructions. Please ensure that you bring any x-rays or scans to the hospital on the morning of the operation. Both the surgeon and anaesthetist will see you before the operation. They will explain the procedure and ask you to sign a consent form. You should confirm which knee is to be operated on and take the opportunity to ask for more information if you wish. At the end of your operation the knee will be filled with local anaesthetic to help with pain relief. In addition your anaesthetist may have used a local nerve block to numb the area in the postoperative period. You will usually stay in hospital for one night following surgery.

ACL Rehabilitation

Your rehabilitation programme is detailed separately. It is important that you proceed through the programme at a steady pace if necessary with guidance from your physiotherapist. The programme involves a series of activities including walking, home and gym exercises, and periods of time on an exercycle. In the initial stages the goals are to reduce the swelling around the knee and regain full extension of the knee. Later in the process the programme works on knee strength and control prior to beginning sports specific training. You must be walking without crutches and you must have full control of your leg to be safe driving.

Ankle Arthroscopy

Ankle arthroscopy or ‘keyhole surgery of the ankle’ involves making a small incision in the joint to allow the internal structures to be observed using a camera. Further incisions can be made to allow instruments to be introduced into the joint to treat a number of conditions affecting the ankle such as damage to the bearing surface, loose bodies and bony spurs. The procedure is usually performed through two small incisions approximately one centimetre long over the front of the ankle. Sometimes a third incision is made at the back of the ankle.

The Operation

Most ankle arthroscopies are performed as a day case procedure. You will be given a time and date for your surgery along with any special instructions. Please ensure that you bring any x-rays or scans to the hospital on the morning of the operation. Both the surgeon and anaesthetist will see you before the operation. They will explain the procedure and ask you to sign a consent form. You should confirm the ankle that is to be operated on and take the opportunity to ask for more information if you wish. At the end of the procedure the ankle itself and the small incisions are injected with local anaesthetic to help with pain relief. In addition your anaesthetist may have used a local nerve block to numb the area in the postoperative period. Finally a padded bandage is applied over the dressings and the foot may be placed in a postoperative splint or orthotic boot.

After the Operation

When you return home you may find that the ankle becomes more uncomfortable as the local anaesthetic wears off. You should take the pain medication given to you according to the instructions as required. Keep the foot elevated as much as possible. If the dressing or splint feels too tight then it is perfectly acceptable to loosen it.

For the first 48 hours following the procedure you should keep the foot elevated as much as possible. The splint/orthotic boot is designed to prevent excessive movement and reduce postoperative pain and swelling and hasten the recovery process.

The dressings on your ankle do not need to be changed until your follow up appointment. This will normally be 6-10 days following surgery.

After the first 48 hours of elevation of your foot it is reasonable to become more mobile on your crutches, putting as much weight through the foot as is comfortable. Walking, however, should be limited to indoors as much as possible.

If you are getting severe pain or other signs or symptoms that concern you please do not hesitate to get in contact using the number below.

Possible Complications

Although the risks of surgery are minimised wherever possible, no procedure is entirely risk-free. Possible complications of arthroscopy of the ankle include anaesthetic complications, wound or joint infections, prolonged wound leakage and deep venous thrombosis (DVT) - blood clots in the calves. It is possible to have some numbness around the scars which usually becomes less noticeable with time.