Arthrodeses/Osteotomies in Foot Reconstruction
Physical Therapy Protocol Information This is a standard program; any unusual circumstances noted by MD or therapist should be clarified and protocol modified as warranted.
Arthrodesis: Surgical fixation of joint with goal of fusion. Osteotomy: Surgical cutting of bone for purpose of realignment or access. Examples: Lapidus (1st TMT fusion with MTP cheilectomy), medial column stabilization (1st TMT, NC arthrodesis), triple arthrodesis (STJ, CC, TN) Forefoot triple (1,2,3 TMT joints). Be aware of concurrent procedures or previously fused joints—protocol defaults to most restrictive precautions.
- Assess current level of function (ADLs/Mobility), ability to manage post-op restrictions, use of assistive devices.
- Screen PMH, condition of UEs and contralateral LE
- Home Env’t: Modifications needed, assistance available, SNF or HH needs.
- Teach post-op mobility restrictions.
- Gait training: NWB/TDWB* (10-15 lbs max) on surgical foot unless otherwise indicated. Must be able to transfer and walk maintaining precautions. Examples of potential gait devices: Crutches, walker, wheelchair, knee scooter, “Peg-leg.” Patient to obtain equipment and bring to hospital.
- General post-op exercise program: ROM, strengthening for UEs, uninvolved leg; AROM/Isometrics gluts, hip, knee, toes of surgical leg unless contraindicated by procedure or condition.
- Teach relaxation techniques and edema management.
- Avoid excessive elevation; arterial circulation can be compromised leading to compartment syndrome. 6-10 inches above heart (1-2 pillows) is sufficient.
- Family/Caregiver training as needed.
- In bed with leg elevated 8-10 inches until 2nd POD.
- AROM exercises for joints above and below surgical sites
- PROM-AAROM toes with metatarsals ** stabilized, foot intrinsics (MTP flexion with PIP/DIP extension), isometrics in cast (observe tendon transfer precautions)
- 2nd POD: – Continue bed exercises. Nursing to get patient up in chair with foot maintained in “1 pillow” elevation for 15-30 mins, e.g. for lunch and dinner.
- Lapidus-type midfoot fusions and other forefoot work: NWB first 2 weeks, then heel WB w/ crutches week 2-4, then WBAT in boot from week 4 on.
- All others: Gait NWB/TDWB on surgical foot. Patient with only distal forefoot bony work may WB through heel if OKd by MD, (no rolling off forefoot). Limit time with extremity dependent.
- If OK’d by MD hindfoot arthrodesis (TN, ST, Triple) may be WB up to 50% in static stance only.
- Home exercise program
- HH, SNF, equipment needs?
** esp. 1st MTP post- cheilectomy
2 week MD visit: Cast change. Sutures out. Edema control training.
Exercises for HEP:
- Continue gentle isometrics in cast, AROM hip, knee, UE exercises.
- Gentle AAROM/PROM toes with metatarsals stabilized.
- Lapidus-type midfoot fusions and other forefoot work: Heel WB w/ crutches week 2-4, then WBAT in boot from week 4 on.
- All others: NWB/TDWB in gait. If only toe/ distal bony work, pt may be W.B. through heel, no rolling off of forefoot
Ankle fusions may be 50% WB 2 weeks post-op, see written orders.
Hindfoot fusion patients may ride stationary bike at 2 weeks post op, hindfoot on pedal if written referral.
Precautions: Progressive WB
- 6 week MD visit: X-ray. Out of cast, into CAM walker boot unless otherwise specified by MD.
- Pt. teaching: Edema control (may need support stockings), scar mobilization, desensitization.
- AROM all available motions with boot off @ least 3 times a day. Begin gentle resistance band strengthening across mobile joints @ 10 weeks post op. Gentle stretching, especially into dorsiflexion (strap/towel stretch) @ 10 weeks post op.
- Gait training — If cleared by MD, begin gradual progression from NWB to full weight bearing over approx. 4 weeks.
- Lapidus-type midfoot fusions and other forefoot work: WBAT in boot until week 8 minimum, then gradual transition out of boot if having zero pain.
- All other: At about 6 weeks post-op: Start at 25% WB, add 25%/week Slow progression if patient develops increased pain.
- At 25% WB (usually) can walk in pool, chest high water.
- Wean off assistive device.
- Sample exercises for home exercise program: Hip muscle strengthening, esp abductors. Low impact conditioning: Pool therapy, stationary bike (when 50% WB)—Have pedal under heel, shoe OK. (Patient should wear boot on bike).
12 week MD visit.
- When comfortably FWB, wean gradually out of CAM boot into a shoe. Shoe modification if needed. May need crutch/cane when first out of CAM.
- Progress resistance band strengthening. –Isometric strengthening across fused joints.
- Appropriate joint mobilization-be aware of fused joints.
- Once FWB in shoe, then progress from bilateral closed chain to unilateral closed chain exercises and more advanced balance/ proprioception exercises.
- Stretching: Avoid creating torque across midfoot or fused joints. Patients with Midfoot/Lis franc fusions should avoid heel raise exercises until cleared by MD.
5-6 month MD visit.
- Maximize quality of gait. Advanced balance, proprioceptive work. Prepare for DC.
- Assess shoes/orthotics to protect surrounding joints. Rocker bottom shoe for ankle fusion, increased cushion for STJ fusion (EG Altra Olympus or Paradigm). Bevel for MTP fusion (also Altra Olympus or Paradigm).
- Jumping/high impact activities not recommended.
- Functional assessment e.g. single leg stance balance and reach, step ups, heel raises.
Note: Stop unilateral heel raises if painful at fusion site.