patient information and rehabilitation guidelines following high … · 2016-05-13 · this booklet...
TRANSCRIPT
This booklet aims to improve your understanding of high tibial osteotomysurgeryandtherehabilitationafterwards.
Osteoarthritiscanaffectanyjointinthebodybutismorecommoninjointsinthelowerlimbweight-bearingjoints,eghipandknee.
Ajointisformedwheretwobonesmeet.Theendsofthebones,whichformthejoint,arecoveredinarticularcartilage.Thisprovidesasmooth,slipperyandlowfrictionsurfacethatalsocushionsthejoint.Healthycartilageabsorbsstressandallowsthebonestoglideacrosseachothersmoothly.
Theword arthritismeans joint inflammation. Also known as ‘degeneration’ or‘wearandtear’arthritis,osteoarthritisisthemostcommontypeofarthritisanddevelopsoveralongperiodoftime.It affects the articular cartilage,which can start towear away. Sometimes thisaffectsonesideofthekneejointmorethantheother.
PatientInformationAndRehabilitationGuidelinesFollowingHighTibialOsteotomySurgery
Anatomy
Osteoarthritis
This isanoperation,whichaims tochange theweightbearing forces thatpassthroughtheknee.Ifyouhaveosteoarthritis(wearandtear)anditonlyaffectsonesideoftheknee,itmaybeappropriatetohaveaHTO.The operation is aimed at younger patients to avoid/delay total kneereplacement.Thisisbecausetotalkneereplacementdoesrestrictactivitylevelsandhavingoneatayoungagemeansitismorelikelytowearout.
Painisusuallythecommoncomplaint.Thisoperationaimstoreduceorgetridofthe pain. It has a success rate of 70-90%. Other benefits include improvedlifestyleanddelaytofullkneereplacement.
Alternativestosurgeryinclude:
§ Conservative measures, these include painkillers anti-inflammatories,usingawalkingstick.
§ Kinespringimplantation:theinsertionofashockabsorberundertheskinbutoutsidethekneejoint.
§ A unicompartmental (or partial) knee replacement. This replaces theosteoarthriticsideofthejointandreplacesitwithmetalandplastic.Thisisstillakneereplacement,itdoesnotallowyoutoreturntohighimpactactivities (e.g. running). In younger patients it is likely towear out andrequirerevision.
§ Totalkneereplacement.Thisremainsanoptionbutinyoungerpatientsittooislikelytowearoutandrequirerevision.Italsowillnotletyoureturntohighimpactactivities.
TheProcedure
Whatishightibialosteotomy(HTO)?
Benefitsofsurgery
AlternativestoHTOsurgery
Theshinbone(tibia)iscut.Apieceofboneistakenfromthefrontofthepelvisandthisbonegraftisplacedintothecutmadeintheshin.Ametalplate(theAOTomofixplate)isusedtoholdthecuttibiaandbonegraftinplace.Thekneecanchange position so that instead of the leg being straight it can look knockedkneed.Thisisnormal.
Complicationsdooccur.Someareminorandsomerequirefurthersurgery.Itisimportant you understand this before proceeding with surgery. Examplesinclude:Complication Recordedin
literatureProfessorMcNicholas’cases
Anaestheticrisks(discussedwithyouranaesthetist)
Notrecorded
Notrecorded
Delayedbonehealing 4% 4%
Fractureintothekneejoint
4% Notrecorded
Superficialinfection 3.4-7.1% 7%Deepinfectionintothejoint
4%
Notrecorded
Complications
Theprocedure
Kneestiffness 14% Notrecorded
Deepveinthrombosis(clotinthecalf) 4% Notrecorded
Pulmonaryembolism(clotinthelung) 1-2% 7%Compartmentsyndrome
0-0.02%
Notrecorded
Temporarynerveinjury 2-25% 7%
Permanentnerveinjury 4.7-14% Notrecorded
ReflexSympatheticDystrophy(abnormalpainreaction)
0.4% Notrecorded
Furthersurgerytoknee
33%at10years54%at15years
Notrecorded
Conversiontototalkneereplacement
15%at5years47%at10years
21%at3years
Donorsiteproblems
20%
7%
Ifyousmoke,youneedtostopbeforetheoperationascontinuingtosmokecouldcausethebonenottohealandincreaserisksofchest infectionandclots inthelegortothelung.Youmaybegivenaninjectionofbloodthinnertoreducetheriskofclotproblems.Any surgical intervention can theoretically result in mortality (death), it isextremelyrareforthistohappenforthisprocedurebutrecentlegalrulingshavemandatedthisbementioned.
Anassessmentof your fitness toundergo surgery includingadetailedmedicalhistory, height, weight, blood pressure and pulse will be performed beforesurgery.Bloodtestsandahearttrace(ECG)mayalsobeneeded.
You are asked not to drink or eat anything for at least 6 hours before youroperation.You will be seen by Professor McNicholas and your Anaesthetist before youroperation.In the anaesthetic room, youwill have aneedleput into your armandwill beplacedonananaestheticmachine.Surgeryusuallytakesaround1hour.
Pre-operativeAssessment
TheDayoftheOperation
Youwillwake-upinthetheatrerecoveryroom.Onreturntothewardyouwillhavethefollowing:
§ Dressings–woolandcrepebandageonthekneeandasplint§ Dripsanddrains–theremaybesmalltubesinthebackofyourhand.You
mightalsohaveatubeintoyourbladder(catheter).§ Analgesia– thismaybeoralmedicationorpatient controlled analgesia
(PCA),whichlookssimilartoadrip.
You can be discharged from hospital if progressing well, managingexercises,andsafeonthestairs.
Thewoundistobekeptdryuntilhealedandthedressingisnottobedisturbedunlesssoiledandacleanoneapplied.Regulariceapplication(10-15minsevery1-2hours).Youwillbegivenpainrelievingmedicationstotakehomewithyou,pleasetakethese asprescribed topreventpain frombuildingup to a level that is hard tocontrol.Physiotherapy appointment arranged. Expect bruising in the thigh and lowerleg.Rememberyourscarishighlysusceptibletothesun,anduseofahigherfactorsunblockisadvised.
Returntoworkwilldependgreatlyonthejobthatyoudo(desk-basedjobs2-4weeks;manualjobs6-12weeks;jobsrequiringladdersetc.3-4months).Returntodrivingat6weeksformanualgearedcarsandautomaticcarsifitistherightlegthathasbeenoperatedon.Ifitistheleftlegthathasbeenoperatedon,youmaydriveanautomaticcaroncethewoundsarehealedat2weeks.You should notify your insurance company of the procedure that has beenundertakentoensurethatyourcoverisvalid.Forfurtherinformationfollowthisweblink:https://www.gov.uk/driving-medical-conditionsFlying is not permitted for 8weeks following surgery due to a higher risk ofdevelopingabloodclot.Forfurtherinformationfollowtheweblinkbelow:http://www.nhs.uk/chq/Pages/2615.aspx?C%20ategoryID=69
DischargeInstructions
GeneralAdvice
Youwillbeseenat2weeks,3,6,12weeksand3,6,9,12months,2,5,10yearsannuallyafterthat.
6-12weeks
Anx-raywillbeusedtocheckiftheboneishealing.Ifnot,weightbearingmayneedtoberestrictedbutthisisveryunusual.
12weeks+
Another x-ray is used to see whether the bone is fully healed. If it lookssatisfactorythecrutchesarenolongerneeded.
Ifthebonehealingisveryslowaspecialmachinecanbeusedtostimulatebonegrowth.Thisisdonearound3-4monthsaftertheoperation.
0-6weeksUsingaplatecalledanA.O.Tomofix,youwillhaveasplintonthefirstdayuntilyoucanstraightlegraise,thennosplintwouldbeneeded.Youmayweightbearastoleratedandmovementofthekneeisallowed.Youwillprobablyneedelbowcrutchesfor6-12weeks.Thefollowingexercisesneedtobecarriedout4timesaday.1. Bend and straighten your ankles briskly. Repeat 10times.
2. Lying on your back or sitting with legsstraight. Pull your toes up towards you andpush your knee down firmly against the bed.Hold5seconds.Repeat10times.
Follow-up
Rehabilitation(Physiotherapy)Programme
3.Sittingwithbacksupported.Placearolledtowelunder your knee. Pull your toes up towards you,straightenyourkneeandpushitdownagainstthetowel.Hold5seconds.Repeat10times.
4. Sitting on a chair or bed with the leg to be exercisedsupported as shown. Use a rolled towel under the heel ifsitting on a bed. Let your knee straighten in this position.Hold5seconds.Repeat10times.
5.Sitonachair.Pullyourtoestowardsyou,tightenyourthighmuscle and straighten your knee. Hold 5 seconds. Repeat 10times.
6.Sittingonthebedplaceasockonyourfoot.Placeaslipperyboard/trayunderyour footandabandaround it.Bendyourknee as far as possible. Gently pull the band to bend a littlemore.Hold5seconds.Repeat10times.
7.Lyingonyoursidesupportingyourselfonyourelbow.Rolltophipslightlyforward,usetoparmtosupportyourself in front.Keepingtoplegstraightlift it up towards the ceiling. Make sure the legstays in line with your body and toes pointforwards.Repeat20times.
VTEisacollectivetermfortwoconditions:
§ DVT (deepveinthrombosis)–thisisabloodclotmostcommonlyfoundinadeepveinthatblockstheflowofblood.
§ PE(pulmonaryembolism)–apotentialfatalcomplicationwhereabloodclotbreaksfreeandtravelstothelungs.
Whilstyouarelessmobile,especiallyduringthefirstfewweeksfollowingyourprocedure,theriskofVTEishigherbecauseofyourimmobility.
VTE(bloodclots)
ProfessorMcNicholasmayprescribeyouadailyinjectionofClexanetohelpthinyourbloodand these should last approximately14days. If this isneeded, youwillbeshownhowtoinjectthisdrugyourself.Symptoms:
§ Swelling – youwill have some swelling due to your surgery but if youhaveanyconcernspleasecallforadvice
§ Pain–anynewpainwewanttoknowabout§ Calftenderness§ Heatandrednesscomparedwiththeotherleg§ Shortnessofbreath§ Chestpainwhenbreathingin
ThingsyoucandotopreventVTE
§ Movearoundasmuchaspossible.Besensiblethough,shortandregularmovementisbest
§ Drinkplentyofwatertokeepyourselfhydrated§ Westronglyadviseyounot to smoke– thiswillhavebeendiscussed in
preopbutwecanalsoreferyoutooursmokingcessationteamwithintheHospital.
§ Move your ankle around asmuch as possible to keep your calfmusclepumping
Smallpreventativemeasurescanhaveahugeimpactonyourrecovery.Writtenby: MsAHatcher,OrthopaedicPhysiotherapistSpecialist
MrRichardNorris,OrthopaedicPhysiotherapistSpecialistProfessorMJMcNicholas,ConsultantOrthopaedicSurgeon
Editedby: MissFRashid,OrthopaedicRegistrarDatelastreviewed: April2016