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ORIF Tibial Plateau Fracture Post-op Normal ROM Questions

VolFan0927

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Hi all,
I am new to forum and have questions related to tibial plateau fracture post surgery ROM progression. My wife had a fall 2 months ago, and fractured TPF, and tore lateral meniscus. Lateral plate and 6-7 screws placed, meniscus repaired. She has osteoporosis and osteogenisis imperfecta. She is 9 wks post surgery, with flexion around 83 and extension at -3. She is doin outpatient PT 2-3x a week. We switched to new PT this week, as felt they were no focusing enough on ROM. New PT has started strengthening exercises (to partial WB up to 50% in the next couple weeks, including Alter G treadmill - OS approval). Prior history of vertebral fractures, but active before surgery. Her knee is still stiff, but doesn't have pain. PT does not think scar tissue at this point is problematic, but OS wants 100+ ROM at next visit in 10 days. Any experiences or thoughts welcome. We are concerned about limited ROM and ability to improve once we get to 3 mo post surgery. She has seemed to plateau in ROM progression, but we made the switch to PT only this week - and they seem more competent.
Thanks


TPF Surgery and Left Meniscus Repair 2/11/21
 
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Pumpkln

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@VolFan0927 ,
Welcome to BoneSmart, glad you joined us!! :welome:
IMO, Your wife's flexion and extension fine for only two months out from surgery. Given her history of osteoporosis and osteogenesis imperfecta, I would hope that everyone is going easy on her knee to avoid further fracture.

I gained ROM 18+ months after my TKR revision. She has plenty of time to gain ROM. Time for her knee to heal, swelling and inflammation to go down and reveal her ROM.

Your new PT should be working on getting swelling down with gentle retro grade massage, electrical stimulation, teaching your wife gentle ROM movements.
At home when your wife is not up moving around, she should be resting, icing, and elevating her knee.
Plateau's are normal while her knee is healing, give it time and ROM start to improve again.

We recommend these two gentle activities for ROM.
Heel slides and how to do them and Extension: how to estimate it and ways to improve it .

Here is your copy of the Knee Recovery Guidelines, the articles are short and will not take long to read.

Knee Recovery: The Guidelines
1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary
2. Control discomfort:
rest
ice
take your pain meds by prescription schedule (not when pain starts!)​

3. Do what you want to do BUT
a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

5. At week 4 and after you should follow this

6. Access these pages on the website


The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly
Chart representation of TKR recovery
Healing: how long does it take?

Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds


We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

While members may create as many threads as they like in the majority of BoneSmart’s forums, we ask that each member have only One Recovery Thread. This policy makes it easier to go back and review the member’s history before providing advice, so please post any updates or questions you have right here in this thread.
 

Jaycey

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PT does not think scar tissue at this point is problematic, but OS wants 100+ ROM at next visit in 10 days.
Well, what the OS wants and what your wife can do at this point are two very different issues. You and your wife need to be very firm - no pushing ROM. Numbers don't mean anything at this point. The gentle approach pays off every time. But it does take time. The ROM will come when that knee is ready.
 

Jockette

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You can’t expect a knee to have a certain ROM number by a certain date, healing doesn’t work that way, as we all heal on a different time frame. I, also, had improved ROM in my second, and even third, year post op.

Regaining our ROM is more about Time than repetitions of a list of exercises.

Time to recover.
Time for pain and swelling to settle.
Time to heal.

Our range of motion is right there all
along just waiting for that to happen so it can show itself.

In the general run of things, it doesn't need to be fought for, worked hard for or worried about. It will happen. Normal activity is the key to success.
 
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VolFan0927

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Thanks. This is helpful. We are trying to better understand importance of early ROM and its impact on scar tissue formation. We are more scared and nervous that we are not hitting the OS goals of ROM, and if that means something worse could happen down the line. My wife had 5 knee surgeries, including a Gortex Ligament on her other knee - and she is fearful of a repeat of that episode. I am trying to assure her that right now is time for healing, lets be consistent, but not too aggressive in our ROM, and it may take months and a gradual improvement.
 

Jaycey

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We are more scared and nervous that we are not hitting the OS goals of ROM, and if that means something worse could happen down the line.
All it will mean is that it will take more time to increase ROM. But I really would not pay any attention to the OS and their goals. It's all about reaching your wife's goals while staying comfortable.

Slow and steady does it every time!
 
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VolFan0927

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Thanks Jaycey. This helps.
Curious if there are others at Bonesmart who have had tibeal plateau fractures.
 

Celle

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We are trying to better understand importance of early ROM and its impact on scar tissue formation. We are more scared and nervous that we are not hitting the OS goals of ROM, and if that means something worse could happen down the line.
There are two types of scar tissue.

First, there's normal scar tissue, which is part of normal healing. It's necessary, because it's what holds your incision together. Without it, you would continue to have an open wound.

Then there's abnormal scar tissue, more correctly called adhesions. This is the one your PT gets all anxious about. But she/he has no need to - it's a lot more rare than you'd think, to hear them talking about it.
MUA (Manipulation under Anaesthetic) and Adhesions

"Bad scar tissue", (adhesions,) isn't just sitting there waiting to pounce if you don't gain good ROM early in recovery. That's a myth that should have died long ago.

There's no need to rush to get early ROM (Range of Motion) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

What's more, it's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee has the potential to achieve good ROM right from the start, but it's prevented from doing so by swelling and pain. As it heals and the swelling goes down, your ROM (both flexion and extension) will increase spontaneously, whether you do formal PT or just let your normal Activities of Daily Living (ADLs) be your exercise.

I am trying to assure her that right now is time for healing, lets be consistent, but not too aggressive in our ROM, and it may take months and a gradual improvement.
Keep telling your wife this. There's no need to rush. She has plenty of time.
I'll give you both some examples in my next post.
 

Celle

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Here are the promised examples from people whose ROM development was slow, but who achieved good results in the end:

First from Campervan. As you can see, her flexion continued to improve for a long time.
"I had a slow recovery. Here's my flex measurements at various points:
92 - 8 weeks post op
105 - 10 weeks
107 - 5 months
110 - 6 months
112 - 7 months
116 - 9 months
119 - 11 months
118 - 1 yr
120 - 1yr 2 months
125 - 1 yr 8 months
128 – 6 years "


Next, from bertschb:
"I'm 12 months out from my surgery and have some advice based on my experience:
1- Stop going to PT (all it will do is make your knee swell and reduce ROM)
2- Don't worry about your ROM
3- Be patient - VERY patient!!!

Here is my ROM history (more or less):
1 month - 60 degrees
2 months - 80 degrees
3 months - 85 degrees
4 months - 90 degrees
5 months - 90 degrees
6 months - 110 degrees
7 months - 120 degrees
8 months - 125 degrees
9 months - 130 degrees
10 months - 135 degrees
11 months - 140 degrees
12 months - 140 degrees

I spent waaaaay too much time worrying about ROM. I thought I'd be riding my bike a couple months after surgery but it took SIX months! Looking back on my surgery, if I knew then what I know now, I wouldn't have wasted my time with PT and I wouldn't have worried about ROM."


Finally, from TortiTabby:
"Just an update for those who are apprehensive about gaining ROM:
It has now been 26 weeks and all I do is ADL and this is what my ROM has done:
3.5 wks: 75
6 wks: 85
7 wks: 90
10.5 wks: 95
14 wks: 100
17 wks: 105
20 weeks: 110
26 weeks (where I am today): 120!!!
I did it! My goal of 120! No "pushing through pain", no PT after the first 3 visits, and most importantly to me: No MUA! My surgeon who said I would never get beyond 85 ROM without pushing through pain was wrong, wrong, wrong. I'm excited to see if it gets even better. :happydance:"
 
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VolFan0927

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Thanks Celle. A followup question -

The abnormal scar tissue noted in TKR, how similar in progression would we expect in a fracture surgery? Our new PT wasn't overally concerned about that now in the low ROM. Perhaps that is why they are focusing more now on core exercises to prepare my wife to stand in the next week?
 

Celle

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The abnormal scar tissue noted in TKR, how similar in progression would we expect in a fracture surgery?
Very similar. Adhesions are a lot more rare than the fuss everyone makes about them.
 

liam2015

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Hi ~ Sorry about your wife's fractured tibia. I had ORIF surgery on Dec. 20, 2020 after slipping on ice, walking my dog, and fractured my femur. The break was right above my knee replacement from 2017; luckily my knee was okay.
My experience with TKR is that it took 7 months before I could rotate pedals on my bike and walk comfortably up and down stairs. I did go to physio, but didn't start until 6 weeks post op, to the chagrin of my surgeon, who kept suggesting an M.U.A., which I refused and after he consulted with his colleagues at a big city hospital, he told me they agreed that I could continue to gain r.o.m. without the M.U.A. The p.t. did massage, knee flex and extend, laser, TENS and cold pack for 20 minutes. I had home exercises but I didn't do them consistently as I don't like causing myself pain or even discomfort. I found out 2 years ago that my R.O.M. was at 125 degrees, measured by another p.t., after I broke my elbow.
I'm 3-1/2 months post surgery after femur fracture and still using a walker, and now a pole (just using one for now) at the suggestion of my p.t. The therapy I get is: massage, p.t. flex and extending my knee (ouch), laser, TENS and hot pack on knee and thigh for 20 minutes. The exercises I do at home (not consistently) are heel slides and leg lifts, plus now the pole walking. In a way I'm anxious to finish up with p.t. and let my leg heal on it's own.
I agree with the advice from the others about not forcing the r.o.m.; elevating and icing, plus walking around if comfortable. I only go once a week to p.t. now, for the first 2 weeks it was twice a week but I found that to be too much for me between getting ready (no weight bearing and huge brace) and hubby working fulltime with his own knee injury. Now we're both going to p.t. together lol.
Your wife has had a tough time with her leg ~ hope she recovers without too much pain.
 
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VolFan0927

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My wife fell on a tile floor in the bathroom. She fractured her tibia plateau in multiple places, and tore meniscus - about 2.5 months ago. The OS wants increased ROM understandably. She is around 90 degrees now. Biggest challenge is flexion, as she can straighten her leg out in extension. Her new PT is introducing new exercises, about 6-8 in last 2 sessions, but has been focusing on ROM, hip flexors, calves, back, hamstrings, and Quads. She was exhausted yesterday, but mainly in areas related to her leg muscles and lower back (she had previous back fractures - so we are monitoring this closely). She is having residual muscle soreness after her sessions.

I have told her be patient on ROM, and asked the PT yesterday how much improvement of ROM is through the exercises being done now vs. normal at home movement. He mentioned he was focusing both on ROM and muscle strength. She can progress to 50% weight bearing now on her broken tibia, but realistically it will take her another 3-5 weeks I think before she is doing that.
Thanks for sharing and hope your recovery goes well.
 
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VolFan0927

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My wife is 8.5 wks PO from TPF, and going to PT 2-3x a week. She is doing heal slides at home, pushbacks, peddles, calf raises, and leg lifts. PT suggested she do exercises with a couple small blow up balls for hip flexors and abs also. It is challenging for her to get ready for PT (non weight bearing, brace to move also), but I have arranged my work schedule to make sure we have time to go to PT. She is anxious as the PT showed her the Alter G Treadmill yesterday (which allows body weight to be reduced) to accommodate partial weight bearing. She is nervous, but wants to use it if it will allow her to begin walking slowly without having to use her upper body to support her (shoulder issues from over use with walker).
 
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VolFan0927

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She uses a walker to ambulate. She trys not to hop on one leg, as the good leg had 5 knee surgeries, including a ligament replacement. So I try to assist her when she goes from chair to car or PT table. She uses walker otherwise. She put 20 pounds last week on it, and we have approval to go to 50% next week. She doesn't want to use crutches, although that might change when she use them to assist when walking on both legs. She is going slow, as she has osteogenisis imperfecta (brittle bone disease), so her bone healing may take a little longer. She definitely is exhausted getting out, especially if we go out and then come home. Although at 9 weeks PO, starting to get a little stir crazy staying in.
 

Celle

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Hi @VolFan0927
I've copied a couple of your posts from liam2015's thread, because they contain information about your wife's progress that aren't in your own thread.

I didn't realis your wife has osteogenesis imperfecta, for example. That's another reason not to try and rush her recovery, or to try and force ROM development. Don't forget to mention to the PT that your wife has brittle bone disease. It's a warning to him not to push her too fast or too much.

Slow and steady, and gentle, should be the aim for her recovery.
 
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VolFan0927

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Thanks Celle. We have been pressing this point about going slow. A couple of times we had to slow PT down, so a good suggestion. Trying to gauge how much of an impact this will have, but we are estimating things are slowed down at least 25%. OS told us for example, that most by 8 weeks PO can consider full weight bearing after surgery, but with my wife it will most likely be 12-16 weeks PO.
I assume similar improvements in ROM, although OS has a reputation for being aggressive, but mainly to minimize flexion contracture.
 

Jockette

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Some surgeons and PTs believe aggressive is the way to rehab, but that doesn’t mean you have to agree and do it that way. There are many opinions about rehab, and you have every right to yours, there is no one way to do it. Go with gut feelings, and your wife’s comfort level, as to how she rehabs this injury.
Saying no to therapy - am I allowed to?
You can say no to parts that you don’t agree with.
 

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