REHABILITATION PROTOCOL FOR OPENING WEDGE PROXIMAL TIBIAL OSTEOTOMY WITH ALLOGRAFT BONE GRAFT

DOCTOR: Robert F. LaPrade, M.D., Assistant Professor, University of Minnesota Sports Medicine Institute, University of Minnesota

Goals:

Individual goals may be established outside of this protocol for some patients who may have other concurrent surgeries or bone quality outside of normal. The opening wedge osteotomy should be treated as a proximal tibial fracture (which in essence it is in a controlled situation) which must be treated very cautiously in the initial period after surgery to allow bone healing. In addition, the patient should avoid the use of nicotine. Range of motion is encouraged in the early postoperative period to prevent scarring of the joint, but weight bearing should be minimized until cleared by the surgeon.

Post-Op Days 1-3:

1. The main goal during this initial period is to obtain patient comfort and to verify the quadriceps mechanism has initiated normal firing.

2. Ambulation with crutches is initiated. The patient should be instructed in strict nonweight bearing technique. Quadriceps sets and straight leg raises are allowed in a knee immobilizer only. The immobilizer should be worn at all times except when the patient comes out of the immobilizer 4 times a day to work on gentle active range of motion of the knee. Aggressive flexion should not be allowed at this point in time.

Post-Op Weeks 1-6:

1. During this time, healing of the osteotomy and incorporation of the bone graft is anticipated.

2. The patient is kept on strict nonweight bearing.

3. Gentle active range of motion outside of the knee immobilizer is allowed initially for 4 times a day and this may increase as strength allows.

4. Frequent straight leg raises in an immobilizer throughout the course of the day are encouraged to get the quadriceps mechanism firing adequately. The immobilizer should be worn throughout this period to minimize the stress on the osteotomy site.

Post-Op Weeks 7-8:

1. At this point in time, it is anticipated that further healing of the osteotomy site is occurring.

2. The patient is allowed to provide further stimulation to the healing process by initiation of range of motion and general quadriceps strengthening with an exercise bike.

3. Minimal resistance should be applied through the stationary bicycle. The patient should start initially at a slow speed and primarily work on range of motion. The speed can be increased as tolerated depending upon the patient's symptoms. The patient is kept on strict nonweight bearing during this time.

Post-Op Week 9:

1. Based upon surgeon approval, the patient is allowed to initiate weight bearing. Patient should show radiographic evidence of healing at this point.

2. The use of the immobilizer may be discontinued at this point in time. Weight bearing should be advanced slowly and should be discontinued if the patient shows any evidence of pain in the joint or at the osteotomy site.

3. The patients will initially start out with the use of 2 crutches of pain in the joint or at the weight bearing with 2 crutches over the course of 7 to 14 days. Once this is achieved, they would be allowed to graduate to the use of 1 crutch under the contralateral arm.

4. Once they can ambulate with full weight and no limp, they can graduate to using no crutches. At this point in time, they can start leg presses to a maximum of 40 lbs. They can perform 3 sets with a maximum of 20 repetitions on a daily basis.

Post-Op Months 3-4:

1. At this point in time, the osteotomy should be healed and the patient should be able to ambulate normally without a limp. Based on evidence of radiographic healing, the patient is allowed to increase activities as tolerated.

2. The use of the exercise bike may be increased to 20 minutes daily with resistance as tolerated. Leg presses may also be increased to a maximum of half body weight as tolerated.

3. Patients should also continue to work on a general strengthening program which will consist of ambulation to a maximum of 2 miles daily. Low impact activities should be stressed.

Post-Op Months 5-6:

1. The patient should be allowed to return to full low impact activities as tolerated.