Post-surgical Knee Rehabilitation

Last week I saw a shocking case of a 68 year old lady who had a right total knee replacement six months ago.  She was unable to walk for more than five minutes, could stand for approximately 10 minutes (but weight bearing predominantly on the left leg), had a 30º flexion contracture and was generally miserable.  She is an intelligent lady with reasonable insight who had been informed on three subsequent reviews by her orthopaedic surgeon that things were progressing satisfactorily adn to “keep doing what she was doing”.

Despite the obvious curiosity regarding the type of outcome measure the surgeon was using (apart from the obvious one of surviving the operative procedure!!), I drilled a little deeper to see if there were complicating co-morbidity factors, recent change in her function subsequent to surgical follow-up – which may not have been evident on  the three previous surgical reviews. Despite my best efforts I was unable to determine any other subsequent factors associated with a recent change in clinical features.

Incidentally, this lady is a keen golfer routinely playing 18 holes three times a week and continued to do so with pain until two months pre-surgery. (why did she opt for surgery I hear you say –and that discussion is for another day!!) She remained active in golf club management and was highly motivated to return to playing, but realised that her current situation completely prohibited this.

What struck me most about this somewhat shocking state of affairs, was that this lady had had no active rehabilitation other than the immediate post-operative input sufficient to allow her to be discharged from hospital.  It was apparently on the repeated instructions of the surgeon to continue “doing what she was doing”, as things were going well.

I raise this issue now, because I have seen an increasing trend in recent years of patients presenting some months post-surgery reporting little or no active rehabilitation and little or no guidance from the surgeons regarding what is required to regain function.  In my 22 years of clinical practice it is not surprising to find some orthopaedic surgeons relatively “pro-physio” whilst others somewhat indifferent.  What I found most shocking in this case was the abdication of what I would call ‘a duty of care’ to do what is best for the patient.

I would fully acknowledge that we may not have sufficiently robust randomised controlled clinical trials to validate the use of post-operative rehabilitation in hip replacement surgery, knee replacement surgery, lumbar spine discectomy and anterior cruciate rehabilitation, but these are all specific examples of clinical cases which I have seen in the last number of years, where patients have been expected to find their own way through self-directed rehabilitation program.  What does this tell us about surgeons insight into  understanding human function and the multiple components such as strength, range of motion, proprioception, co-ordination, motor control, endurance and dynamic loading capacity which this kind of ‘wait and see’ management plan leaves to chance.

In the off chance that I was seeing a skewed clinical case load of resistant conditions, I have discussed this issue with several of my colleagues over recent years, only to discover that it is not an isolated situation.  It is often dictated by the attitude of the surgeon, the extent of rapport between physiotherapy and surgical departments and the environment in which care is provided (public versus private).  Whilst one could conceivably argue in a public setting that cost saving measures dictate that routine follow-ups and rehabilitation not be part of the standard protocol unless patients are exhibiting complications, it is a particularly hard strategy to justify in the private sector.  If insurance companies are covering the cost of treatment and the surgical procedure has been performed without complications, surely it is in the best interests of all concerned to follow a pre-emptive strategy optimising return to function in as quick as possible time, as opposed to waiting for complications to develop.

I would fully acknowledge that these economics may not be applicable to all facets of public sector delivery, and wonder if this is now a case of Evidence Based Practice distorting the clinical realities of patient satisfaction, compliance, and exercise capacity to actually deliver optimal functional outcomes.

Whilst no fan of spurious litigation which encourages claims of negligence and malpractice, I wonder how long it will be before this aspect of duty of care is explored in the courts – if it hasn’t already been?

I think it comes down to matching expectations of surgeon, patient and rehabilitation specialist in order to ensure that there is a congruent match between the acceptable outcomes.

I remain baffled by the concept that a replacement or reconstructed joint can recover spontaneously to its optimal level by a self-directed program in the majority of patients – even with technical detail on what the objectives are. I have treated many physiotherapists over the years and re-enforce this view that it is not always easy to see the “wood from the trees” as a patient and that’s in a client group with specific knowledge .

I would love to know if any of our readers have had similar experiences or  knowledge of a body of evidence which could be presented to surgeons for the type of cases I have described above. Maybe this is a reflection of the profile of physiotherapy rather than a commentary on Orthopaedic surgeons? I would love to hear your comments.

Enjoy the clinical challenge.

David

GHTime Code(s): dea3a e66e2 

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