Image Credit: The Orthopedic Hospital
“Keep your vitality. A life without health is like a river without water.”- Maxime Lagacé
Joint health is one of those health related topics that we never really think about until they become critical. With the myriad of root causes, in some circumstances, there will be a need for orthopaedic surgery to be executed in order to heal the condition at hand. Such surgical procedures include joint replacement. If such a treatment plan is meant for you, your orthopaedic surgeon will indicate this to you during your assessments.
Before any surgical procedure, it is critical that you as a patient are prepared mentally and physically. The healing process does induce pain, and most patients have to ready themselves for the changes to come. The aim of this article is to introduce you to the process involved in the orthopaedic surgical treatment process.
As a start, you will need to do the following:
Have a detailed discussion with your orthopaedic surgeon. Ensure that you have a thorough understanding of your process. The themes you discuss with your surgeon can include: procedure name, anaesthetic applied, implant type, pain management strategy and time to full recovery. This discussion will be by no means exhaustive, you will have to do your research in order to ensure that you are an informed patient. Your health is not only in the hands of your surgeon. The more prepared and informed you are, the better your procedure will be for you and your family.
Reference this article for further discussion questions: Total Joint Replacement: Questions Patients Should Ask Their Surgeon
TYPES OF PROCEDURES IN JOINT HEALTH
The list below is by no means exhaustive, but in the joint health treatment you can expect procedures such as these:
Unilateral/Bilateral:
• Bilateral: unable to unload onto other foot so may be slower to progress
• Need double post-op treatment session times
Lesser Toes:
• Straighten toes 2 +/- 3
• IPJ joint fusion with pin +/- osteotomy to shorten metatarsal
Need to tape MTPJ into flexion post-op.
• Do not attempt to flex IPJS
Midfoot Fusion:
• TMT 2+3: longer immobilisation period up to 10 weeks
• The more procedures the greater the swelling expected. Consider using a Cryocuff post
operatively
Pre-habilitation
Being well prepared for surgery can minimise pre-operative pain; improve mobility; assist preparation for their post-operative care; address any concerns they may have; and contribute to achieving an excellent surgical outcome.
Big Toe:
• Improve 1st MTP mobility in to abduction and extension with specific trigger point and soft
tissue release of adductor hallucis oblique and transverse heads and flexor hallucis brevis including insertions. Note: Adductor hallucis connects to the sheath of peroneus longus which may also need to be released. (see how to treat your own bunion link at the end of these notes)
Release lateral capsule of 1st MTP with big toe in abduction
• Mobilise sesamoids in distal and medial/lateral direction
• Mobilise 1st MTP joint with dorsal and lateral glides
Lesser Toes:
Improve 2nd +/- 3rd MTP and IPJ mobility in flexion and extension with specific trigger point and soft tissue release of extensor digitorum longus and brevis and flexor digitorum longus and brevis and joint capsules as required.
Screening:
• Check for foot, knee hip or back pain due to pain avoidance and lateral foot loading
• Check and release tibialis anterior and peroneus longus, lateral foot and lateral hip rotators.
• Assess balance
Arrange:
• Pre and post-op manual lymphatic drainage massage from a suitable qualified therapist.
Shoes: to match 4cm heel height of post-op shoe (fit flops sandal or heel lifts in joggers) Stretchy upper shoe to accommodate swelling after immobilisation period eg Sketchers, Nike Free Cast protector to keep dressing dry when showering
• Pedal exerciser to improve circulation and prevent DVT
Exercise bands: Light and medium resistance for rehab exercises. Crutches or walking stick may be required if having a nerve block or multiple procedures Provide post-op protocol and go through exercises, taping and bandaging (coban 1.5cm width x 4)
• Post-operative appointments from week 4
Surgery Preparation
As with anything in life, preparation is key to success. As a patient, it will be important for you to ensure that you have all your relevant documentation ready for your surgery such as your insurance documentation, and any legal documentation that you may need to sign pertaining to your understanding of the risks of your medical procedure. Ensuring that you have all your medical details ready will make your preparation more effective. A checklist of information you can have on hand can include:
Contact Information for relatives and doctors
Detailed medical conditions to ensure that there are no other potential underlying issues such as allergic reactions to medications. If you are on any narcotics, tell your doctor.
Insurance Company details
Once you have your details ready, it will be time to prepare for your surgery. As a start, the healthier you are entering the surgical room, the faster will be your recovery time. If you can, take the time to improve your eating habits, stop drinking before your surgery, reduce or quit smoking and take all the steps you can to improve your blood circulation. A balanced diet will help you to achieve your objectives. Once the surgical procedure is completed, the next steps for your healing include your post-operative care.
Post-Operative Care
Post Operative Care involves the series of activities that are involved in your post surgical care. As a patient, there will be part of your post surgical care that will take place in the hospital itself. Once you are discharged however, you need to ensure that plans are in place to facilitate the final stages of your healing. The following checklist includes a list of objectives that will be critical to you as a patient in the completion of your therapy. Keep these in mind as you proceed through your healing, so that you can query any discrepancies that may arise as you progress.
Aims:
• Reduce swelling
• Maintain toe in position of abduction and external rotation (toe nail rotated towards
lesser toes)
Wound care
• Monitor progression of post-operative exercise programme
Restore mobility to all MTP joints and sesamoid bones as per prehab instructions
• Restore strength of big toe flexors and intrinsic muscles
Address compensatory changes through lower limbs and pelvis due to altered gait Restore balance
Restore 1st MTP loading during stance
• Restore calf strength
Swelling:
• Digital caps and compression garments without toes may be required depending on
the amount of swelling. Take care to avoid applying coban bandages too tightly as this may cause local nerve irritation felt as a stinging or burning sensation.
Wound care:
• When treatment starts at week 4, thoroughly wash the area with anti-bacterial wipes
and antiseptic soap to remove any dead skin. Wear gloves and place protective disposable covering on the treatment table. Check wounds for any sign of infection or tethering Use Cica Care silicon gel sheet for any sensitive or tethered scars once wound is closed and revise scar mobilisation.
Site Disclaimer: “‘Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.’
Your health is your health. For additional details visit the links below:
Useful links
Trigger point guide:
http://www.triggerpoints.net/
A physiotherapists experience of Minimally Invasive Bunion Surgery:
How to manage your Bunion: A Self-treatment Guide:
http://www.jointhealth.com.au/articles/how-to-look-after-your-bunion
Preparing for Foot and Ankle Surgery:
http://www.jointhealth.com.au/articles/preparing-for-foot-ankle-surgery
Preparing for Joint Replacement Surgery:
https://orthoinfo.aaos.org/en/treatment/preparing-for-joint-replacement-surgery/
References
1. Phys Ther. 2009 Sep;89(9):934-45. doi: 10.2522/ptj. 20080375. Epub 2009 Jul
16.Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase.Schuh R?, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ. http://www.ncbi.nlm.nih.gov/pubmed/19608631
Clin Podiatr Med Surg. 2014 Apr;31(2):309-22. doi: 10.1016/j.cpm.2014.01.002. Epub 2014 Feb 26.Physical therapy post-hallux abducto valgus correction.Hawson ST http://www.ncbi.nlm.nih.gov/pubmed/24685196
