Post-Operative Instructions Fasciotomy for Chronic Exertional Compartment Syndrome

Transcription

1 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery Chief, Divisin f Sprts Medicine T Pst-Operative Instructins Fascitmy fr Chrnic Exertinal Cmpartment Syndrme Day f surgery A. Diet as tlerated B. Icing is imprtant fr the first 5-7 days pst-p. While the pst-p dressing is in place, icing shuld be dne cntinuusly. Once the dressing is remved, ice is applied fr 20-minute perids 3-4 times per day. Care must be taken with icing t avid frstbite. C. Pain medicatin as needed every 4-6 hurs (refer t pain medicatin sheet). D. Make sure yu have a physical therapy pst-p appintment scheduled during the first week after surgery. First Pst-Operative Day A. Cntinue ice pack every 1-2 hurs while awake B. Pain medicatin as needed. Secnd Pst-Operative Day Until Return Visit A. Cntinue ice pack as needed. B. Unless therwise nted, yu can bear as much weight n the affected leg as yu can tlerate. Mst patients use crutches r a cane fr the first 1-3 days. The amunt f pain yu experience shuld be yur guide fr discntinuing crutch r cane use. C. Call ur ptin 4, ptin 2 t cnfirm yur first pstperative visit, which is usually abut 1-2 weeks after surgery. If yu are experiencing any prblems, please call ur ffice r cntact us via the internet at Third Pst-Operative Day A. Yu may shwer this evening. Yu MUST keep the extremity dry while shwering. After shwering, remve surgical bandage and apply fresh 4x4 surgical spnges/gauze t the incisin and wrap with and ACE bandage. Yu will need t fllw this rutine fr 2 weeks after surgery. B. N baths with leg immersed under water fr 1 mnth after surgery. NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F

2 Dr. Laith M. Divisin f Sprts Medicine Jazrawi Chief, Assciate Prfessr Department f Orthpaedic Surgery Rehabilitatin Guidelines Fllwing Cmpartment Syndrme Release With Open Fascitmy Chrnic Exertinal Cmpartment Syndrme (CECS) is a painful cnditin f the lwer leg that affects many runners and ther athletes invlved in repetitive impact activities. The pain assciated with this cnditin is thught t be abnrmal pressure in the cmpartments f the lwer leg. The lwer leg is cmprised f fur universally described cmpartments anterir, lateral, superficial psterir, and deep psterir (Figure 1). Bne and cnnective tissue structures define the varius cmpartments in the lwer leg. The cmpartments have relatively fixed vlumes and surrund muscles, arteries, veins and nerves. Cmpartment syndrme ccurs when increased pressure impedes bld flw thereby impairing functin f tissues within the lwer leg.1 Unlike acute cmpartment syndrme, CECS is nn-emergent. CECS is a reversible frm f abnrmally increased pressure in the cmpartment that ccurs during exercise/exertin f tissues that are nncmpliant with increased muscle vlume during exercise.1,2 The exact physilgical cause f CECS remains unclear but it is thught t be multi-factrial. Cntributrs t CECS may include: increased muscle size, cnnective tissue thickness r stiffness, decreased bld flw, and micrtraumatic injuries.3 Factrs inherent t the individual may include leg length differences and malalignment f the lwer leg. Other factrs may include: muscle imbalances r weakness, lack f endurance, decreased flexibility, incrrect mvement cntrl patterns, and training intensity r frequency.4 The incidence f CECS in thse with chrnic exercise-induced leg pain ranges frm 14-27%.5 Seventy percent f patients with CECS in the anterir cmpartment are runners.1,6,7 The cnditin is nearly evenly split between males and females.7 CECS has been reprted in the frearm, thigh, hand and ft hwever 95% f cases ccur in the lwer leg.7 Symptms in bth f the legs ccur in 85-95% f thse affected.8 Thse affected with CECS ften cmplain f dull, aching, r cramping pain lcalized t the cmpartment affected in the lwer extremity at the same duratin f time (minutes) fllwing the initiatin f each episde f exercise.9 Cnfirmatin f the diagnsis is made with needle cmpartmental pressure testing at rest and fllwing exercise.5,7,8,9 If rehabilitatin is unsuccessful, surgical management may be the treatment chice fr CECS in the active ppulatin. Specifics f surgical decmpressin vary, but many include: pen fascitmies r fascitmies with partial fasciectmies.9 An pen fascitmy typically invlves 1-2 large incisins where cnnective/fascial tissue is cut. A partial fasciectmy describes a prcedure in which a prtin f the cnnective tissue/ fascia is remved. Surgical treatment can be perfrmed as an utpatient prcedure under lcal anesthesia.10 A carefully planned and implemented rehabilitatin prgram is imprtant fr a patient t achieve ptimal functinal utcmes pstperatively.11 Back View Supraspinatus Fibula (b ne) Deep Psterir Infraspinatus Teres Lateral Minr Superficial Psterir Anterir Frnt View Tibia (bne) Subscapularis Figure 1. Lwer leg cmpartments th St. New Yrk, NY (646) newyrkrth.cm!

3 Rehabilitatin Guidelines Fllwing Cmpartment Syndrme Release With Open Fascitmy Phase I (Day 1 t Day 14 after surgery) Gals Pain Management Prevent Swelling Precautins Crutches and PWB x 2 weeks AROM hip and knee Wiggle tes, gentle ankle AROM DF/PF as tlerated Straight leg raises (SLR) x 4 Upper bdy exercises (seated r bench nly n pushups) LE stretches hamstring, quads, ITB, hip flexrs Other Suggestins Ice and elevatin Phase II (2 weeks t 4 weeks fllwing surgery) Gals DF/PF AROM WNL Precautins Prgress t WBAT (d/c crutches) Cntinue apprpriate previus exercises Calf pumping, alphabet, rtatins Gentle DF stretch w/ twel Light Theraband exercises x 4 Twel crunches and side-t-side Seated BAPS Statinary bike (n resistance) Leg press < 25% bdy weight and pain-free Calf press < 25% bdy weight and pain-free Other Suggestins Cmpressin stcking if persistent swelling Ice as needed th St. New Yrk, NY (646) newyrkrth.cm!

4 Rehabilitatin Guidelines Fllwing Cmpartment Syndrme Release With Open Fascitmy Phase III (4 weeks t 6 weeks fllwing surgery) Gals 10 single leg hell raises Nrmal walking gait x 1 mile Precautins WBAT Scar massage (if incisin well healed) Cntinue apprpriate previus exercises Steambats (Theraband x 4 while standing n invlved LE) Mini-squats, wall squats, ttal gym Duble leg heel raises prgress t single leg heel raises Duble t single leg BAPS, ball tss, and bdy blade Treadmill walking frwards and backwards Elliptical trainer Pl therapy chest r shulder deep water running (ptinal) Phase IV (6 weeks t 12 weeks fllwing surgery) Gals Strength via weight machines 90% f nn-invlved 45 minutes lw impact cardi 5/week Walk 2 miles at 15min/mile pace with minimum symptms Cntinue apprpriate previus exercises Prgressive strengthening prgram Leg press and hip weight Knee extensin and HS curl weight machine Fitter, slide bard Push-up prgressin Sit-up prgressin Prgressive lw-impact cardi prgram Stairmaster Pl therapy- unrestricted th St. New Yrk, NY (646) newyrkrth.cm!

5 Rehabilitatin Guidelines Fllwing Cmpartment Syndrme Release With Open Fascitmy Phase V (12 weeks t 16 weeks fllwing surgery) Gals Pass APFT at 4 mnths pst-p Run 1 mile at 12 min/mile pace with min symptms at 3 mnths Cntinue apprpriate previus exercises Running prgressin prgram when fllwing criteria met: Pain-free 2 mile walk at 15min/mile pace N pst-exercise swelling Transitin t hme/gym prgram 2x per week Agility Drills/ Plymetrics th St. New Yrk, NY (646) newyrkrth.cm!

6 Rehabilitatin Guidelines Fllwing Cmpartment Syndrme Release With Open Fascitmy 1. Styf, J. Definitins and terminlgy. Etilgy and pathgenesis f chrnic cmpartment syndrme. In: Cmpartment syndrmes: diagnsis, treatment, and cmplicatins Bca Ratn, FL. CRC Press LLC. 2. Wilder, RP. Exertinal cmpartment syndrme. Clin Sprts Med. 2010;29: Leccq J, Isner-Hrbeti ME, Dupeyrn A, et al. Exertinal cmpartment syndrme. Ann Readapt Med Phys. 2004;47: Anuar K, Gurumrthy P. Systematic review f the management f chrnic cmpartment syndrme in the lwer leg. Physitherapy Singapre. 2006; 9: Turnipseed WD, Hurschler C, Vanderby R Jr. The effects f elevated cmpartment pressure n tibial arterivenus flw and relatinship f mechanical and bichemical characteristics f fascia t genesis f chrnic anterir cmpartment syndrme. J Vasc Surg. 1995;21: Anuar K, Gurumrthy P. Systematic review f the management f chrnic cmpartment syndrme in the lwer leg. Physitherapy Singapre. 2006; 9: Bng MR, Platsch DB, et al. Chrnic exertinal cmpartment syndrme: diagnsis and management. Bulletin f NYU Hsp fr Jt Diseases. Winter-Spring Shah SN, Miller BS, Kuhn JE. Chrnic exertinal cmpartment syndrme. Am Jur Orth. 2004; Gill CS, Halstead ME, Matava MJ. Chrnic exertinal cmpartment syndrme f the leg in athletes: evaluatin and management. Physician and Sprtsmed. 2010;38: Wittstein J, Mrman CT III, Levin LS. Endscpic cmpartment release fr chrnic exertinal cmpartment syndrme. Am Jur Sprts Med. 2010;20: Hutchinsn MR, Llyd Ireland M. Cmmn cmpartment syndrmes in athletes: treatment and rehabilitatin. Sprts Med. 1994;17: Kisner, C, Clby LA. Surgical interventins and pstperative management, the ankle and ft. In: Exercise: Fundatins and Techniques. 5th Editin Philadelphia, PA. F. A. Davis Cmpany. 12. Schubert, AG. Exertinal Cmpartment Syndrme: Review f the Literature and Prpsed Rehabilitatin Guidelines Fllwing Surgical Release. Intern Jur Sprts Phys Ther. 2011; 6: th St. New Yrk, NY (646) newyrkrth.cm!

7 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery Chief, Divisin f Sprts Medicine T Pst-Operative Rehabilitatin Prtcl: Fascitmy fr Chrnic Exertinal Cmpartment Syndrme Patient Name: Date: Days 1-14: Gals: Crutches and PWB x 2 weeks - Pain management AROM hip and knee - Prevent swelling Wiggle tes, gentle ankle AROM DF/PF as tlerated Straight leg raises (SLR) x 4 Upper bdy exercises (seated r bench nly n pushups) LE stretches hamstring, quads, ITB, hip flexrs Ice and elevatin Weeks 2-4: Gals: Prgress t WBAT (d/c crutches) - DF/PF Cntinue apprpriate previus exercises - AROM WNL Calf pumping, alphabet, rtatins Gentle DF stretch w/ twel Light Theraband exercises x 4 Twel crunches and side-t-side Seated BAPS Statinary bike (n resistance) Leg press < 25% bdy weight and pain-free Calf press < 25% bdy weight and pain-free Ice as needed Cmpressin stcking if persistent swelling Weeks 4-6: Gals: WBAT - 10 single leg heel raises Cntinue apprpriate previus exercises - Nrmal walking gait x 1 mile Scar massage (if incisin well healed) Theraband exercises x 4 gradually increase resistance Steambats (Theraband x 4 while standing n invlved LE) Mini-squats, wall squats, ttal gym Duble leg heel raises prgress t single leg heel raises Duble t single leg BAPS, ball tss, and bdy blade Treadmill walking frwards and backwards Elliptical trainer Pl therapy chest r shulder deep water running (ptinal) NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F

8 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery Chief, Divisin f Sprts Medicine T Weeks 6-12: Gals: Cntinue apprpriate previus exercises - 45 min lw-impact cardi 5/week Prgressive strengthening prgram - Strength via weight machines Leg press and hip weight machine 90% f nn-invlved Knee extensin and HS curl weight machine Fitter, slide bard Push-up prgressin Sit-up prgressin Prgressive lw-impact cardi prgram - Walk 2 miles at 15min/mile pace Treadmill walking prgressin prgram with minimum symptms Stairmaster Pl therapy - unrestricted Weeks 12-16: Gals: Cntinue apprpriate previus exercises - Run 1 mile at 12min/mile pace Running prgressin prgram when fllwing criteria met: with min symptms at 3 mnths 3 x 20 heel raises with LE strength 90% f uninvlved - Pass APFT at 4 mnths pst-p Pain-free 2 mile walk at 15min/mile pace N pst-exercise swelling Agility drills/plymetrics Transitin t hme/gym prgram 2x per week Cmments: Signature: Date: NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F