Tibial Tubercle Osteotomy & Arthroscopic Lateral Release

Recovery after knee surgery entails controlling swelling and discomfort, healing, return of range-of-motion of the knee joint, regaining strength in the muscles around the knee joint, and a gradual return to activities. The following instructions are intended as a guide to help you achieve these individual goals and recover as quickly as possible after your knee surgery.

COMFORT
- Elevation
  - Elevate your knee and ankle above the level of your heart. The best position is lying down with two pillows lengthwise under your entire leg. This should be done for the first several days after surgery.
- Cold Therapy
  - If you elected to receive the circulating cooling device, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 20-30 minute intervals.
  - If you elected to receive the gel wrap, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
  - If you elected to use regular ice, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the ice.
- Medication
  - Pain Medication-Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication.
    - You have been provided a narcotic prescription postoperatively. Use this medication sparingly for moderate to severe pain.
    - You are allowed two (2) refills of your narcotic prescription if necessary.
    - When refilling pain medication, weaning down to a lower potency or non-narcotic prescription is recommended as soon as possible.
    - Extra strength Tylenol may be used for mild pain.
    - Over the counter anti-inflammatories (Ibuprofen, Aleve, Motrin, etc.) shoulder be avoided for the first 4 weeks following surgery.
  - Anti-coagulation medication: A medication to prevent post-operative blood clots has been prescribed (Aspirin, Lovenox, etc.) This is the only medication that MUST be taken as prescribed until directed to stop by Dr. Forsythe.
  - Nausea Medication – Zofran (Odansetron) has been prescribed for nausea. You may take this as needed per the prescription instructions.

Constipation Medication - Colace has been prescribed for constipation. Both your pain medication and the anesthesia can cause constipation. Take this as needed.

ACTIVITIES
- Locking Knee Brace – The brace is to be worn for up to 4-6 weeks following surgery. It will be locked straight until bone healing and good knee strength have been achieved (usually 5-6 weeks after surgery). At that time your doctor will determine if your leg has enough strength to allow your brace to be unlocked. You may unlock the brace while sitting but lock the brace before standing. Sleep with the brace on until directed by Dr. Forsythe.
- Exercises – These help prevent complications such as blood clotting in your legs. Point and flex your foot and wiggle your toes. Thigh muscle tightening exercises should begin the day of surgery and should be done for 10 to 15 minutes, 3 times a day, for the first few weeks after surgery.
- CPM – (Continuous Passive Motion Machine) – A Continuous Passive Motion (CPM) machine maybe started the day after your surgery. This machine will be set at 30°. Motion on the machine should be increased at 10-15° per day or as much as tolerated, to a maximum of 110° in one week. The machine should be used 6 hours per day (i.e. 2 hours in the morning, 2 hours in the afternoon and 2 hours in the evening). Use of the machine will continue for 1-2 weeks, or until maximum flexion of the machine is reached (110°).
  - DO NOT WEAR LEG BRACE OR COOLING DEVICE WHILE USING CPM MACHINE.
- Weightbearing – You are allowed to put partial weight on your operative leg with only your toe touching the ground. Keep your brace locked in a straight position. Walk using two crutches or a walker. You may touch your foot on the floor for balance. Do this within the limits of pain. You are allowed to put full weight on your leg after 1 week.
- Physical Therapy– PT is usually started a 1-2 weeks after surgery. You should call the physical therapist of your choice for an appointment as soon as possible after surgery. A prescription for physical therapy, along with physical therapy instructions (included in this packet) must be taken to the therapist at your first visit.
- Athletic Activities– Athletic activities, such as swimming, bicycling, jogging, running and stop-and-go sports, should be avoided until allowed by your doctor.
- Return to Work– Return to work as soon as possible. Your ability to work depends on a number of factors – your level of discomfort and how much demand your job puts on your knees. If you have any questions, please call your doctor.

WOUND CARE
- Bathing - Tub bathing, swimming, and soaking of the knee should be avoided until allowed by your doctor - Usually 4-6 weeks after your surgery. Keep the dressing on, clean and dry for the first 3 days after surgery.
  - You may shower 3 days after surgery with WATERPROOF band-aids on. Apply new band-aids after showering.
- Dressings - Remove the dressing 3 days after surgery. Your stitches will be left in until about 1-2 weeks post-op. You may apply band-aids to the small incisions around your knee and cover your larger incision with sterile gauze or large band-aids. If you have steri-strips (small white band-aids) they can remain in place until your first office visit.

EATING
- Your first few meals, after surgery, should include light, easily digestible foods and plenty of liquids, since some people experience slight nausea as a temporary reaction to anesthesia

CALL YOUR PHYSICIAN IF:
- Pain in your knee persists or worsens in the first few days after surgery.
- Excessive redness or drainage of cloudy or bloody material from the wounds (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor.
- You have a temperature elevation greater than 101°
- You have pain, swelling or redness in your calf.
- You have numbness or weakness in your leg or foot.

RETURN TO THE OFFICE
- Your first return to our office should be within the first 1-2 weeks after your surgery. Call your physician’s office to make an appointment for this first post-operative visit.

REHABILITATION PROGRAM:

Tibial Tubercle Osteotomy & Arthroscopic Lateral Release

NOTE: The following instructions are intended for your physical therapist and should be brought to your first physical therapy visit.

The intent of this protocol is to provide the therapist with guidelines of the post-operative rehabilitation course after a Fulkerson/Tibial Tubercle Osteotomy. It should not be a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course based on their physical exam findings, individual progress, and/or the presence of post-operative complications. The therapist should consult the referring physician with any questions or concerns.

PHASE I (0-6 weeks)

A. Goals

Control inflammation and pain
Protect soft tissue and tubercle fixation
CPM to 90 degrees (60 degrees when medial imbrication is also performed)
Full active extension and 90 degrees of flexion
Achieve quadriceps control

B. Brace

Locked in extension for 6 weeks during ambulation
Sleep with brace locked for 4 weeks, then discontinue for sleep
May remove for CPM and exercises except straight leg raises

C. Weight-Bearing Status

Weight-bearing as tolerated with crutches and brace locked in extension after 1 week

D. Therapeutic Exercises

Straight leg raises in all planes (use brace locked in extension for SLRs)
Heel slides to 90 degrees, calf pumps, quadriceps sets
Electrical stimulation and biofeedback to regain quad function
Patellar mobilization
Ankle ROM and resistive exercises with sports tubing (Theraband)

PHASE II (6- 8 weeks)

E. Criteria

Good quad set, straight leg raise without extension lag
90 degrees of knee flexion
Full extension

F. Goals

Increase ROM
Establish normal gait with unlocked brace

G. Brace/Weight-bearing status

Continue with full weight bearing
Use crutches and unlock brace for ambulation, when quad is ready
May discontinue crutches and brace when normal gait pattern and quad control is achieved

H. Therapeutic Exercises

Increase ROM
Progress to SLRs without brace
Mini-squats (0-45 degrees)
Stationary Bike (high seat, low tension)
Closed chain extension (leg press:0-45 degrees)
Pool walking/jogging
Toe raises
Hamstring and gastroc/soleus stretches
Proprioception
- Mini-tramp standing
- Stable and unstable platform (BAPS) with eyes open and closed
- Standing ball throwing and catching

PHASE III (8-12 weeks)

I. Criteria

Normal gait
Full range of motion
Sufficient strength and proprioception to initiate functional activities

J. Goals

Improve confidence in the knee
Protect the patellofemoral joint
Progress with strength, power, and proprioception

K. Brace/Weight-Bearing Status

Discontinue brace and crutches

L. Therapeutic Exercise

Continue with flexibility exercises
Hamstring curls
Mini-squats and leg press to 60 degrees
StairMaster, elliptical trainer, cross-country ski machine, lap swimming
Stationary bike, increase resistance
Step-up, start 2 inches and increase to 8 inches
Continue to work on proprioception and balance (lateral slide board, ball throwing and catching on unstable surface)
Treadmill walking

PHASE IV (3 months+)

Criteria