High Tibial Osteotomy Surgery
Here are guidelines that will help you in preparing for high tibial osteotomy surgery
PREOPERATIVE INSTRUCTIONS WITHIN A FEW WEEKS BEFORE SURGERY:
Your doctor will see you in the office. He will do a preoperative history and physical examination and complete the necessary paperwork. It is recommended that you utilize a stationary cycle to maintain
your knee range of motion and improve the overall function of the knee prior to surgery.
SEVERAL DAYS PRIOR TO SURGERY:
Wash the knee several times a day with soap or Hibiclens solution to get it as clean as you can. This decreases the risk of infection. Be careful not to get any scratches, cuts, sunburn, poison ivy, etc. The skin has to be in very good shape to prevent problems. You do not need to shave.
THE DAY BEFORE SURGERY:
Please be in touch with your doctor's office to confirm the exact time that you should report to the hospital for surgery. You can have nothing to eat or drink after midnight on the day before surgery. It is very important to have a completely empty stomach prior to surgery for anesthesia safety reasons. If you have to take medication, you can do so with a sip of water early in the morning prior to surgery (but later tell the anesthesiologist you have done so).
DAY OF SURGERY:
Bring any crutches, brace, ice machine or imaging studies that you have received.
SURGERY:
HIGH TIBIAL OSTEOTOMY (HTO) is a surgical procedure aimed repositioning the knee joint, realigning the mechanical axis of the limb so that less pressure/body weight goes through the worn area of your knee. This distributes your weight more evenly through both sides of the knee. The surgical technique involves making an incision over the tibia, below the knee joint. A wedge of bone is removed, based on the surgeon’s calculations, to allow the angle of the knee to be adjusted. The space created in the tibia is filled with a bone graft taken from the crest of your pelvis or hip bone and a metal plate and screws is used to hold the tibia in position while it heals. some cases, the doctor will perform microfracture surgery in combination with the HTO.
MICROFRACTURE is a surgical procedure is performed in order to attempt to promote articular cartilage regeneration. This arthroscopic technique involves clearing damaged tissue from the knee joint and creating tiny holes ("microfractures") in the bone area where the articular cartilage is worn and degenerated. The underlying bone marrow seeps out through the holes and becomes part of a blood clot that forms over the area. The marrow contains stem cells, which have the ability to form replacement cartilage between the bare-bone surfaces of the knee. Appropriate rehabilitation of the knee after urgery is critical to the success of the operation.
You will use a Continuous Passive Motion (CPM) machine at home where
the knee is moved gently by the machine for 10 out of 24 hours a day for 2 weeks (6 weeks if you have an HTO plus microfracture). You will use crutches and keep all of your weight off of the joint for a period of 6 weeks, and then partial weight
bearing with crutches for an additional 6 weeks. Consistent adherence to our physical therapy protocol following surgery will enhance the success of the procedure.
AFTER SURGERY:
Prior to surgery, a continuous passive motion (CPM) machine will be delivered to your home. This is a small apparatus that sits on the bed onto which your knee rests. The CPM very slowly bends and straightens out the knee. You will be able to adjust the CPM with a hand-controlled unit.
Start the machine from 0 to 50 degrees and advance to 100 degrees as tolerated
CMP Usage Guidelines
HTO Only | HTO and Microfracture |
---|---|
Use CPM 10 out of 24 hours Use CPM for 2 weeks |
Use CPM 10 out of 24 hours Use CPM for 6 weeks |
You can get up whenever you want to but it is best to get up more frequently for short periods of time.
Dressing
The dressing should be changed the day following surgery and can be removed at two days. The wound is sealed with steri-strips (small pieces of tape on the skin). You can shower on the second day following surgery, but be careful standing in the shower so that you do not fall. It is better to have a small stool to be able to sit on. However, you can get the leg wet and wash it.
Do not submerge the knee under water in a bath, hot tub or swimming pool.
Cold Therapy
You will also receive a cryocuff. The cryocuff is a closed loop cuff that circulates cold water and provides compression around you knee to help minimize swelling and pain. You can use this as often as you want to cool down the knee to reduce swelling and pain. Check your skin every time that you remove the wrap to make sure that it is intact.
Physical Therapy
You should make arrangements to start physical therapy between 3-5 days following your surgery. Your therapist will help make sure you understand the program we want you to follow and assist you in making sure all exercises are performed correctly. If it is convenient for you, we would be happy to see you at MGH Sports Physical Therapy, or we can help you determine where you want to do your post op rehab. If you will be seeking rehab services elsewhere, contact your physical therapist directly.
***If you develop calf pain or excessive swelling in the leg, call your doctor's office.***
HTO Rehabilitation Protocol
This protocol is a guideline for your rehabilitation after high tibial osteotomy surgery. Please call our office if you are having a problem with your knee or if you need clarification of these instructions.
PHASE I: 0 – 2 weeks after surgery
You will go home with crutches, cryocuff cold therapy unit and a CPM machine. GOALS:
- Protect the osteotomy – avoid weight
- Ensure wound healing
- Attain and maintain full knee extension
- Gain knee flexion (knee bending) to 90 degrees
- Decrease knee and leg swelling
- Promote quadriceps muscle strength
- Avoid blood pooling in the leg veins
ACTIVITIES:
CONTINUOUS PASSIVE MOTION (CPM)
CPM Usage Guidelines
HTO Only | HTO and Microfracture |
---|---|
Use CPM 10 out of 24 hours Use CPM for 2 weeks |
Use CPM 10 out of 24 hours Use CPM for 6 weeks |
Use the CPM machine at home as much as possible. Do not wear the brace when in the CPM machine. You should use the machine at least 10 hours per day. You may move the machine to a sofa, the floor or onto a bed as you change positions and locations. You should use the machine at night while sleeping; slow down the machine at night to facilitate sleeping. Extension (knee straight) on the machine should be set at minus five degrees at all times to help your knee extend. It is very important that you straighten the knee completely! The machine should be programmed to include an extension pause of 5 seconds (in other words, when the knee is straightened out, it pauses in the straight position to allow you to stretch it out straight). This flexion setting will start at around 30 – 40 degrees and should be gradually increased toward 90 degrees as you can tolerate more bending of your knee.
BRACE/CRUTCHES
Unless otherwise instructed by your doctor, use crutches when walking and do not bear weight on the operated leg.
CRYOCUFF (COLD APPLICATION)
If you are experiencing pain, swelling, or discomfort, we suggest icing for 15-20 minutes with at least a 60-minute break in between. Use your cryocuff or place ice in a zip lock bag and/or in a towel and apply to the injured area. Never place ice directly on the skin.
WOUND CARE
Remove your bandage on the second morning after surgery but leave the small pieces of white tape (steri strips) across the incision. You can wrap an elastic bandage (ace) around the knee at other times to control swelling. You may now shower and get your incision wet, but do not soak the incision in a bathtub or Jacuzzi until the stitches have been removed.
5. ASPIRIN / ELASTIC STOCKINGS
Take an aspirin each morning, wear an elastic stocking (TED) that extends above the knee, and do at least 10 ankle pump exercises each hour to help prevent phlebitis (blood clots in the veins).
6. FREE/MACHINE WEIGHTS Upper Body/Trunk Only
Do not use any lower extremity free or machine weights. If you are doing free or machine weights for the upper body and trunk, we suggest a very light resistance of 3 sets of 15-20 repetitions. Do not place yourself in a compromising position with your recently operated knee.
EXERCISE PROGRAM
QUADRICEPS SETTING - to maintain muscle tone in the thigh muscles and straighten the knee.
The tightening action of the quadriceps should make your knee straighten and be pushed flat against the bed or floor. Hold 5 seconds for each contraction. Do 20 repetitions or more, three times a day.Sit or lie on your back with the knee extended fully straight as shown in the figure. Tighten and hold the front thigh muscle making the knee flat and straight If done correctly, the kneecap will slide slightly upward toward the thigh muscle.
HEEL PROP- to straighten (extend) the knee.
Lie on your back with a rolled up towel under your heel or sit in a chair with the heel on a stool as shown in the figure. Let the knee relax into extension (straight). If the knee will not straighten fully, you can place a weight (2 to 5 pounds) on the thigh, just above the kneecap.
Try to hold this position for 5 minutes, three times a day. While maintaining this extended position, practice quadriceps setting.
CRYOCUFF (COLD APPLICATION)
If you are experiencing pain, swelling, or discomfort, we suggest icing for 15-20 minutes with at least a 60-minute break in between. Use your cryocuff or place ice in a zip lock bag and/or in a towel and apply to the injured area. Never place ice directly on the skin.
WOUND CARE
Remove your bandage on the second morning after surgery but leave the small pieces of white tape (steri strips) across the incision. You can wrap an elastic bandage (ace) around the knee at other times to control swelling. You may now shower and get your incision wet, but do not soak the incision in a bathtub or Jacuzzi until the stitches have been removed.
5. ASPIRIN / ELASTIC STOCKINGS
Take an aspirin each morning, wear an elastic stocking (TED) that extends above the knee, and do at least 10 ankle pump exercises each hour to help prevent phlebitis (blood clots in the veins).
6. FREE/MACHINE WEIGHTS Upper Body/Trunk Only
Do not use any lower extremity free or machine weights. If you are doing free or machine weights for the upper body and trunk, we suggest a very light resistance of 3 sets of 15-20 repetitions. Do not place yourself in a compromising position with your recently operated knee.
EXERCISE PROGRAM
QUADRICEPS SETTING - to maintain muscle tone in the thigh muscles and straighten the knee.
The tightening action of the quadriceps should make your knee straighten and be pushed flat against the bed or floor. Hold 5 seconds for each contraction. Do 20 repetitions or more, three times a day.Sit or lie on your back with the knee extended fully straight as shown in the figure. Tighten and hold the front thigh muscle making the knee flat and straight If done correctly, the kneecap will slide slightly upward toward the thigh muscle.
HEEL PROP- to straighten (extend) the knee.
Lie on your back with a rolled up towel under your heel or sit in a chair with the heel on a stool as shown in the figure. Let the knee relax into extension (straight). If the knee will not straighten fully, you can place a weight (2 to 5 pounds) on the thigh, just above the kneecap.
Try to hold this position for 5 minutes, three times a day. While maintaining this extended position, practice quadriceps setting.
HEEL SLIDES - to regain the bend (flexion) of the knee.
While lying on your back, actively slide your heel backward to bend the knee as shown in the figure. Keep bending the knee until you feel a stretch in the front of the knee. Hold this bent position for 5 seconds and then slowly relieve the stretch and straighten the knee. While the knee is straight, you may repeat the quadriceps setting exercise. Repeat 20 times, three times a day.
SITTING HEEL SLIDES - to regain the bend (flexion of the knee).
When sitting in a chair or on the edge of a bed, slide the heel backward as if trying to get the foot underneath the chair. Hold 5 seconds and slowly relieve the stretch by sliding the foot forward. You can help in both directions with the opposite foot. Repeat 20 times, three times a day.
ANKLE PUMPS - to stimulate circulation in the leg.
You should do at least 10 ankle pump exercises each hour.
OFFICE VISIT
Please return to see your doctor approximately ten to fourteen days after your surgery. At this time, your sutures will be removed and your progress will be checked
HTO Rehabilitation Protocol
Phase Two: 2 to 6 weeks after surgery Goals:
- Protect the knee from overstress and allow healing
- Regain full motion
- Begin muscle strengthening
Brace and Crutches:
Unless otherwise instructed by the doctor, use crutches when walking and do not bear weight on the operated leg. When walking with the crutches follow the instructions below:
Walking (‘toe-touch’ non-weight bearing):
- Put the crutches forward about one step's
- Put the injured leg forward; level with the crutch
- Touch the toe of the involved leg to the floor to help you balance but do not bear weight on the
- While bearing all of your weight on the crutches, take a step through with the uninjured leg
Exercise Program
The following exercise program should be followed as directed by the doctor or the physical therapist. Do the exercises daily unless otherwise noted.
STATIONARY BICYCLE
Utilize a stationary bicycle to move the knee joint and increase knee flexion. If you cannot pedal all the way around, then keep the foot of your operated leg on the pedal, and pedal back and forth until your knee will bend far enough to allow a full cycle. Most people are able to achieve a full cycle revolution backwards first, followed by forward. You may ride the cycle with no resistance for 20 to 30 minutes a day. Set the seat height so that when you are sitting on the bicycle seat, your knee is fully extended with the heel resting on the pedal in the fully bottom position. You should then actually ride the bicycle with your forefoot resting on the pedal.
WATER WORKOUT (optional)
Utilize an Aqua jogger floatation vest to run in deep water with no foot contact to the pool floor or swim flutter kick only for up to 20 minutes 2 or 3 times a week
QUADRICEPS SETTING - to maintain muscle tone in the thigh muscles and straighten the knee.
Lie on your back with the knee extended fully straight. Tighten and hold the front thigh muscle making the knee flat and straight. If done correctly, the kneecap will slide slightly upward toward the thigh muscle. The tightening action of the quadriceps should make your knee straighten and be pushed flat against the bed or floor.
Hold 5 seconds for each contraction. Do 20 repetitions three times a day until you can fully straighten your knee equal to the unoperated side.
HEEL PROP - to straighten (extend) the knee.
Lie on your back with a rolled up towel under your heel or sit in a chair with the heel on a stool as shown in. Let the knee relax into extension (straight). If the knee will not straighten fully, you can place a weight (2 to 5 pounds) on the thigh, just above the kneecap.
Try to hold this position for 5 minutes, three times a day. While maintaining this extended position, practice quadriceps setting.
HEEL SLIDES - to regain the bend (flexion) of the knee.
While lying on your back, actively slide your heel backward to bend the knee. Keep bending the knee until you feel a stretch in the front of the knee.
Hold this bent position for 5 seconds and then slowly relieve the stretch and straighten the knee. While the knee is straight, you may repeat the quadriceps setting exercise.
Continue this exercise until you can fully bend your knee equal to the unoperated side. Repeat 20 times, three times a day.
STRAIGHT LEG LIFT
The quality of the muscle contraction in this exercise is what counts the most, not just the ability to lift the leg!
- Tighten the quadriceps (quadriceps setting) as much as you can, push the back of the knee against the floor
- Tighten this muscle harder!
- Lift your heel 4 to 6 inches off the floor
- Tighten the quadriceps harder again.
- Lower your leg and heel back to the floor. Keep the quadriceps as tight as tight as possible
- Tighten this muscle harder again.
- Relax and repeat
If the knee bends when you attempt to lift the limb off of the bed, do not do this exercise. Keep trying to do the quadriceps setting exercise until you can lift the limb without letting the knee bend.
SHORT ARC LIFT
With the knee bent over a rolled up towel or blanket of a height
of 4-5 inches (the knee should be bent only 20-25 degrees), lift the foot so that the knee fully straightens. Hold the knee locked in extension for 5 seconds, then slowly lower. Repeat 20 times.
STANDING HAMSTRING CURL
Stand facing the wall, using the wall for balance and support. while standing on the unoperated limb bend the knee of the operated side and raise the heel toward the buttock. Hold this flexed position for one second. Slowly lower the foot back to the floor. Keep the thighs aligned as illustrated. Repeat 20 times.
ANKLE PUMPS - to stimulate circulation in the leg. You should do at least 10 ankle pump exercises each hour.
HIP ABDUCTION
Lie on your unoperated side. Keep the knees fully extended.
Raise the operated limb upward to a 45 degree angle as illustrated. Hold one second, and then lower slowly. Repeat 20 times.
OFFICE VISIT
Please make an appointment with your doctor at 3-4 months after surgery
Times per day: 1-2 Days per week: 5-7 |
|
---|---|
Hamstring Stretch | 3-5 reps holding for 15-30 sec |
Quadriceps stretch | 3-5 reps holding for 15-30 sec |
Calf Stretch | 3-5 reps holding for 15-20 sec |
Quadriceps Stretch Prone
This stretch is performed in the position illustrated at the right. Bend your knee, grasping your toes, foot or ankle. If you are too tight to do this, loop a belt or towel around your ankle and grasp that. Pull the heel toward the buttock.
When a stretch is felt in the front of the thigh and knee, hold 15 to 20 seconds for 3 to 5 repetitions.
Hamstring Stretch
Perform this stretch in the position illustrated at the right. Bend slowly forward at the hips, keeping the knee fully extended until you feel gentle stretch in the back of your thigh and knee. Hold the stretch for 15 to 20 seconds and repeat 3 to 5 times.
Days per week: 3 | Times per Day: 1 |
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Cycling | |
Days per week: 3-4 Times per day: 1 |
|
Stationary or outdoor (mountain or road bikes) (Stay on flat terrain and remain on seat) |
30-45 minutes |
Stretching Exercises
Times per day: 1-2
Days per week: 5-7
Hamstring Stretch - 3-5 reps holding for 15-30 sec
Quadriceps stretch - 3-5 reps holding for 15-30 sec
Calf Stretch - 3-5 reps holding for 15-20 sec
Straight Leg Lift
Side Abduction Leg Lift
Short Arc Lift (30 degrees or less)
Standing Hamstring Curls
Add 1 lb. per week to reach 5 lbs. 3 sets of 15 repetitions
Squat to Chair
In the chair squat exercise, you lower your buttocks toward the chair until your buttocks touch the chair. Do not sit or rest at the chair, but instead immediately and slowly return to the standing and starting position.
Remember to keep your head over your feet and bend at the waist as you descend. When doing a squat, you should position your thighs so that your kneecaps are in line with the tips of your shoes, or your second toe.
For patellar/trochlear microfracture patients, do only a partial squat about 1/3 way to the chair. The angle at the knee should not exceed 30 degrees to avoid excess stress on the healing cartilage. Do not do this exercise if there is pain or grinding at the kneecap. After the first week, you may hold dumbbells while performing this exercise and the wall slide. Start with 3 to 5 pounds each hand. You may add 2 to 3 pounds per week until you reach 10 pounds in each hand.
3 sets of 10 to 15 repetitions.
Wall Slides
Stand upright with your back and buttocks touching a wall. Place the feet about 12 inches apart and about 6 inches from the wall. Slowly lower your hips by bending the knees and slide down the wall until the knees are flexed about 30 degrees (illustration). Do not slide down deeper than 45 degrees at the knee to avoid kneecap problems (this instruction is especially important for patellar and trochlear microfractures. Pause for five seconds and then slowly slide back up to the upright starting position. When doing a wall slide, you should position your thighs so that your kneecaps are in line with the tips of your shoes, or your second toe.
Do 3 sets of 10 to 15 repetitions.
Step Up- Down Exercise
Place the foot of the operated limb on a stool or step. Maintain balance, if necessary, by holding onto the wall or a chair (illustration). Standing sideways to the step, slowly lower the opposite foot to touch the floor. Do not land on the floor, just touch gently and then step up onto the stool by straightening the knee using the quadriceps muscles. Try to keep an upright posture and avoid bending forward during the exercise. When doing a step up-down, you should position your thigh so that your kneecap is in line with the tip of your shoe, or your second toe. Do 3 sets of 10 to 15 repetitions.
Progression for Step Up-Down Exercise
Start with a step of 3 inches in height. Start with 3 sets of 5 repetitions. Add one repetition per set, per workout, until you can do 3 sets of 10 (about 2 weeks) If pain free, progress to a step of 6 inches in height.
Repeat the above progression starting with 3 sets of 5 repetitions. Add one repetition per set, per workout, until you can do 3 set of 10 (about 2 weeks). If pain free, progress to a step of 9 inches in height (the height of a standard stair). Repeat this process of progression from 3 sets of 5, to 3 sets of 10 (about 2 weeks).
OFFICE VISIT
Please make an appointment to see your doctor in 12 weeks (6 months after surgery).
Rehabilitation after High Tibial Osteotomy Surgery
Post-op Phase | Weight bearing status | Use of brace | Passive ROM and Active ROM | Strength training | Return to running and sports | Recommended Restrictions |
Phase One and Two 0 to 6 weeks |
NWB (toe- touch) with crutches | ?? |
CPM 10 hours /day for the first 2 weeks after surgery
Stationary bike starting the 3rd postop week |
Isometric Quad and knee extension, active and assisted knee flexion, SAQ, straight leg raises, stationary bike | none | Emphasize compliance with weigh bearing restrictions and CPM |
Phase Three 6 to 12 weeks |
PWB 50% with crutches |
Postoperative brace discontinued. |
Full Rom Stationary bike Stretch all muscle groups |
Progressive ankle weight resistance, and wall slides , toe raises. Leg press less than body weight |
none |
No stairmaster o Impact exercises Avoid pivoting a varus/valgus stresses
Limit OC and CC knee extension a to 0-30 for patellar/trochlear |
Phase Four 12 weeks onward |
Progressive WB to full | Per doctor’s advice |
No restrictions
Active stretching all muscle groups
Stationary bike Elliptical trainer |
Continue closed- chain strengthening, Start step-up-down progression Strength machines OK, except no knee extension machine. No leg press for patellar/trochlear microfracture |
Consult doctor |
Avoid patellofemoral overload Limit OC and C knee extension a to 0-30 with patellar/trochlear microfracture |