Orthopaedic AHP Therapy

Illzarov is a circular frame used to hold bones in place; this is a type of external fixation. The frame holds broken bones in place to allow healing through the use of rings and wires. The metal rings will go fully or partly round your leg with the metal wires going through your bone and attaching to the rings. The tension between the rings and wires hold the bones to allow healing, this can take some time and your frame can be on for 6 months to 2 years.

Frames are used for:

• Bone breaks
• Correcting deformities
• Leg lengthening
• Infection of metalwork
• Non-union of bone internal fixation

Rehabilitation is a large part of your recovery once your frame is applied. The physiotherapists and occupational therapists will work with you on the ward from the first day after your surgery until you are fit for discharge home; this will include mobility and other daily tasks such as washing and dressing. It is very important that you work with the physiotherapist and occupational therapists; this is your recovery and your progression relies upon your willingness and co-operation to work with the team looking after you.

If your frame is on the lower half of your leg you will be provided with footwear to fit below the frame and a band will be fitted around the shoe and to your frame to help maintain your ankle movement. See picture below.

Once your frame has been applied, you will be expected to learn and perform exercises that will be explained to you by your physiotherapist. It is important to exercise the joints and muscles around the frame to prevent any other problems that would slow your recovery and to promote new bone formation. The main aim of these exercises is to maintain muscle length and strength. Try to repeat these exercises 3 times per day.

Toe exercises

• Bend and straighten your toes. Repeat 10 times.
• If you find this is difficult and your toes remain in a bent position try to gently straighten them out with your hands – hold this stretch for 30 seconds and repeat 3-5 times.

Ankle exercises

• Lying on your back or sitting. Bend and straighten your ankles briskly. If you keep your knees straight during the exercise you will stretch your calf muscles.
• You can do this against the elastic band that is attached to your frame to make this exercise more difficult.

• A towel looped around the bottom of your foot can help pull your foot into a stretch – you should feel this up the back of your calf. Hold for 30 seconds and repeat 3-5 times.

Knee exercises

1. Knee bend

• Either sitting or lying on your back. Bend and straighten your hip and knee by sliding your foot up and down.
•  Repeat this 10 times.
• If you are struggling with this then you can use a towel to assist with this as shown.

2. Knee Strength:

• Lying on your back with legs straight. Bend your ankles up and push your knees down firmly against the bed. Hold 5 seconds then relax. Repeat 10 times. 

• Inner range Quads: Place a roll underneath your knee. Point your toes to the ceiling, rest the back of the knee against the roll and lift your heel off the bed while straightening your knee. Hold for 3-5 seconds then relax. Repeat 10 times.

• Straight leg raise: Lying on your back with one leg straight and the other leg bent. Exercise your straight leg by pulling the toes up, straightening the knee and lifting the leg 20 cm off the bed. Hold approx 5 secs. – slowly relax. Repeat 10 times.

Knee Stretch:

In sitting or lying. Rest your ankle on a stool or a rolled up towel. Stay in this position for 5-10 minutes to stretch the back of your knee.

Hip strength:

• Lying on your front. Squeeze buttocks firmly together. Hold approx. 5 secs. Relax. Repeat 10 times

•  Sidelying on your non frame side. Keep the leg on the bed bent and the upper leg straight. Lift the upper leg straight up with ankle flexed and the heel leading the movement. Repeat 10 times.

•  Sidelying on your non frame side. Keep the leg on the bed bent and the upper leg straight. Lift the upper leg up 10cm then keeping the ankle flexed and the heel leading the movement take the leg behind you and back. Repeat 10 times.

Hip Strength in Standing

• Hip Extension: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and bring your leg backwards. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier). Repeat 10 times.
• Hip Abduction: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and lift your leg out to the side. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier) Repeat 10 times.

After frame application you can fully weight bear on your leg, you will receive pain killers from nursing staff at regular intervals in the day to allow you to participate in your rehabilitation.

Your physiotherapist will provide walking aids to allow you to mobilise from the first day after your operation, the aid used will vary depending how much support you require. It is advisable that you have pain relief prior to therapy input as this will allow you to get the most out of your time with the therapist.

Walking with a frame

• Place walking frame out in front.
• Step your frame leg first then weight bear down through your arms and step your non-operated leg in to meet it then repeat.
• With therapy input you should move to walking one foot past the other, this encourages heel contact and weight bearing on your frame leg which is important.

Walking with elbow crutches

• You will be progressed to elbow crutches if able
• Place both elbow crutches out in front
• Step your frame leg first followed by your non operated leg.
• When able start to walk one foot past the other again to encourage heel contact and weight bearing on frame leg.

If a handrail is available then always use it as well as one crutch. Your physiotherapist will teach you how to carry your other crutch up and down the stairs as you will need it when you get to the top/bottom. 

Going up stairs

Instructions for climbing upstairs are:

• Place your un-operated leg up onto the step
• Bring your frame leg up to the same step
• Bring the crutch up onto the same step

Going down stairs

Instructions for climbing downstairs are:

• Place your crutch down onto the step below
• Step down with your frame leg
• Bring your un-operated leg down to the same step

Your Occupational Therapist and Physiotherapist will likely ask you to demonstrate your ‘transfers’, i.e. how you move from one surface to another. This includes getting in/out of your bed, and on/off your toilet and chair. You will need to demonstrate that you can safely do these transfers before going home. Your rehab team will offer you advice on techniques, and may recommend specialist equipment to help. Some general tips for transfers are as follows:

Bed

• Sit-down high up the bed to minimise the need to adjust your position later.
• Shifting your weight over each hip in turn can help you shuffle further on/off the bed.
• Lift your leg high to avoid catching your frame or ripping your sheets/mattress. You may have to change which side you sleep on depending on which leg you find easiest to lead with.
• The frame can be very heavy, so your Occupational Therapist may provide equipment to make getting in and out of bed easier.

Toilet

• Your Occupational Therapist will assess your ability to sit down and stand up from the toilet based on information provided about your home
• Do not sit down until the backs of both knees are touching the toilet.
• To sit/stand, stick your affected leg out in front, and bending forward at the hips to put your weight through your unaffected leg.
• To control your movement, your Occupational Therapist may provide you with equipment which gives a sturdy hand-hold, or you can place your hands on the toilet bowl itself for support.      

Chair/sofa

• It is important to choose a chair that is high enough for you to get off easily. Your occupational therapist may provide equipment to raise your chair heights if required.
• A chair with armrests on both sides can be useful to push up from.
• You may wish to elevate your leg for comfort on a stool. Be careful with recliner footrests as your pins may get caught.

Dressing

You will find wearing loose fit trousers, shorts, dresses, skirts or t-shirts ideal for getting on/off over your frame. You may find wearing a bigger size of clothing helps when dressing. When taking clothes on / off over your Ilizarov frame you will be required to be careful of the wires and pin sites You may even wish to cut trousers/ leggings / t-shirt arms above the external fixator. During your hospital stay, your Occupational Therapist will look at you getting dressed to provide further information and equipment to make getting dressed easier if required.

Personal care

You will be advised to try keeping your frame and pin sites dry. It is recommended in between pin site cleans to have a strip wash while sitting on a chair being careful to avoid your pin sites. On the day you are completing pin site clean you can shower beforehand.

Sleeping

When sleeping, you may find it more comfortable sleeping on your back. The metalwork around the frame may cause ripping to your bed sheets, to limit this wrap a pillow case around the External Fixation to protect your bed sheets. Do not place pillows under your frame, this can cause your knee to bend and over time this can limit your ability to fully straighten your knee.

You will be involved in your own discharge planning throughout your rehabilitation including any ongoing needs you may have such as rehabilitation and care package.

Depending on your level of mobility and mobility aid, there are lots of things you will still be able to do for yourself. However, for the more robust activities, it is important to plan, and consider what support you have available to assist you.

Housework

You may still be able to complete basic tasks, for example washing & drying the dishes. In order to make this task easier, consider storing your frequently used dishes and utensils in an easily accessible place at waist height, for example, on the work top, or, an easily reachable cupboard at eye level.

For more robust tasks such as hoovering or changing the bedding, you may want to arrange help. Speak to friends and family about this, or if you are able, privately arrange a cleaner.

Shopping

Your ability to go to the shops will depend on your level of mobility. Being able to attend the shop for groceries should be a goal of yours if you were able to do this before. Initially for convenience, you may wish to speak to friends or family about arranging assistance.

If you have access to the internet, you can also arrange a delivery with a local grocer or supermarket.

Kitchen activity and meal prep

There are many ways you can retain your independence in the kitchen. Your Occupational Therapist will discuss these with you during your assessment.

If there is an able bodied person at home with you, they may be asked to assist you with your meal preparation, and carrying items.

If you live alone, your Occupational Therapist will discuss your kitchen environment, how you will safely transfer items, and may assess you with appropriate equipment depending on your level of mobility at discharge.

Exercises and Mobility

Try not to sit for long periods when at home, go for short walks regularly and keep using your walking aid(s) as instructed by your physiotherapist. Build up your walking distance gradually from short distances around the house to getting out and about.

Continue with your exercises at home 3 times a day.

You will be referred to your local physiotherapy department for ongoing progression of exercises and mobility; they will contact you with appointment once you are at home.

If you are of a working age, and currently in employment, either the Doctor on your ward, or your own GP, can provide you with a sick line as required.

When returning to work, you should speak to your employer’s Occupational Health department. If your employer does not have an Occupational Health department, speak to your GP.

Either your GP or your Occupational Health department can provide advice and guidance with regard to a phased return to work.

You cannot drive with an ilizarov frame. If you drive you must wait until your frame is removed before returning to driving.

Having an External frame fitted can require a big adjustment to you (and your families) life. Following the application of your External Fixation you may find you have emotional ‘ups and downs’. Some frame users have described feelings of:

• Fearfulness
• Loss of identity
• Feeling useless
• Feeling like a burden
• Fear for the future
• Concern regarding pain/infection/your own ability

Prior to surgery you may find it beneficial to think of ways of coping and identifying people whom you could speak to when you feel frustrated and low. Your GP, consultant, nurse and AHP staff are also there to support you, providing advice and/or referring you onto other relevant services in your local area. Very often challenges can be overcome by finding ways to adapt to, or overcome, the situation.

You may also benefit from speaking with other frame wearers at the weekly clinic to share experiences and advice. It is important to remember that every frame-wearer will have a different experience, and it is impossible to predict how you will feel, or what challenges you may come across. 

Useful resources

• Samaritans – 116 123 (freephone)
• Breathing Space – 0800 83 85 87 (freephone)

1. Ankle pumps: Repeat 10 times 3 times per day

2. Ankle strength: start this exercise when exercise 1 becomes too easy.

• Repeat 10 times 3 times per day

3. Knee stretch: hold position for 10mins repeat every 1-2hours

4. Knee flexion: Repeat 10 times 3 times per day

5. Inner Range Quads: Repeat 10 times 3 times per day

6. Straight Leg Raise: lift and hold for 10seconds.

• Repeat 10 times 3 times per day

7. Hip Abduction in lying: Repeat 10 times 3 times per day

8. Hip Extension in lying: Repeat 10 times 3 times per day

9. Hip Extension Standing: can be done as alternative to exercise 8.

• Repeat 10 times 3 times per day

10. Hip Abduction: can be done as alternative to exercise 7.

• Repeat 10 times 3 times per day

OA of the base of the thumb is a very common complaint. Tis is usually due to normal wear and tear, caused by the demands placed on the thumb during everyday activities.

OA at the base of the thumb can cause symptoms of pain and stiffness. You may find some difficulty with gripping and tasks such as opening jars and turning a key in the lock.

Symptoms can often be controlled by non surgical treatments but if they are not effective surgery may be an option. The most common surgery is called a trapeziectomy. Here, we will give you some advice after having a trapeziectomy.

The surgery is generally a day procedure which means you can usually go home on the same day as your surgery. Depending on the procedure it may be performed under local anaesthetic in which you will remain awake or under general anaesthetic in which case you will be asleep.

The surgery involves removing a small bone called the trapezium through a small cut at the base of your thumb.

Removal of this bone gives more space for the thumb to move so that the bone surfaces are not rubbing together causing pain.

Sometimes an additional small cut is made on the front of your forearm in order to get a piece of tendon to use to stabilise the base of the thumb after the small bone is removed.

Please note that as with any surgery there are potential risks involved. The majority of people have straight forward recovery following surgery. However complications can occur and include:

• Infection
• Nerve damage causing altered sensation or loss of feeling in the thumb area.
• Persistent scar tenderness.
• Injury to the arteries of the finger or hand.
• Failure to resolve the pain.

Please contact the clinic on the numbers provided if you have any concerns

Your thumb and hand will be put in a splint or a cast. Your surgeon will advise on when the cast or splint will be removed or changed but this is usually for an overall period of 6 weeks.

If a wire has been inserted, this can be removed after 3 to 4 weeks.

During the time your splint or cast is on, it is important to:

• Keep your hand raised to help get rid of swelling
• Move your fingers to prevent them from becoming stiff
• Do not use your hand for anything other than very light functional activities (eg using telephone, finger typing, turning on a switch)
• Do not drive

You may experience pain and discomfort at first but normally this resolves with time. Please speak to your GP or pharmacist about controlling your pain if necessary.

After the splint or cast has been removed at around 6 weeks after your operation you can now start to exercise your thumb. The exercises are described below. You should try to use your hand as normally as possible but avoid heavy lifting or prolonged tight gripping until around 10 to 12 weeks after the operation. How much you are able to do with your hand at this stage depends on how much pain you are experiencing. it is important to manage your pain to allow you to move your thumb and do your exercises.

Exercise 1

Hold all fingers straight. Make big circles with your thumb. Repeat 10 times.

Exercise 2

Place the back of your hand on a table with your thumb and fingers rested. Bring your thumb across to the base of your little finger as far as you are able. Return your thumb back to the starting position. Repeat 10 times.

Exercise 3

1. Place your elbow or back of your hand on a table. Put the tip of your thumb against each of your fingertips in turn. Repeat 10 times.
2. Practice picking up small objects.

Exercise 4

Bend the upper joint of your thumb. Assist the movement with your other hand. Hold for 15 seconds. Repeat 10 times.

You can return to driving when your cast or splint has been removed finally (usually around 6 weeks after your operation) and it is comfortable and safe for you to do so. You must feel that you are in complete control of the car; it is your responsibility to check with your insurance company before returning to driving.

Time Off Work

This will depend on your occupation, place of work, ability to return to light duties and may at times be dependent on whether the operation has been carried out on your dominant hand or not.

Please remember that recovery of full function can take a long time, in some cases it can be 6 months or more before you can carryout any heavy functional tasks.

A knee arthroscopy is a common orthopaedic operation which involves looking into the knee joint with a fine telescope. It allows the surgeon to see inside the knee and treat several conditions. It is performed under a general anaesthetic, which means that you will be asleep throughout the procedure.

Preparing for Your Appointment

• Please see your day surgery appointment and guide booklet for further instructions. It is important that you read and follow these instructions fully.
• Please wear loose fitting trousers, e.g. track suit bottoms as you will have a bulky bandage on your knee after your surgery.
• Do not shave your knee.

• You can expect some discomfort around the wound area. The painkiller tablets given to you before going home should help. We will advise you how to take these. Within the first 24-48 hours, if you have severe pain in your knee not relieved by the painkillers or if your knee becomes very swollen, you should seek advice.
• Do not take alcohol while taking pain killers.
• You can help to reduce pain and swelling by raising your leg several times a day and using ice over the knee for 10-15 minutes. (It is important to wrap the ice in a damp towel to protect from ice burn)

Wound Healing

• The wounds will take approximately 1 week to heal.

Stitches

• Normally there are no skin stitches.
• Small sticky tapes have been applied.
• Please make an appointment with your GP 10 days following your surgery to have your stitches removed (if applicable).

Wound Dressing

• You may have a padded bandage on top of the dressing. Please remove the padded bandage 24 – 48 hours after your operation.
• You will have a dressing covering your wound. Remove the dressing after 24- 48 hours. 
• Some surgeons like you to replace the bandage with a tubigrip to proved knee support.
• The tubigrip should be worn over the knee from 3 to 4 inches above to 3 to 4 inches below the knee.
• Continue to wear the tubigrip until the swelling goes down. It should be worn all day but removed at bedtime.

Wound Care

• Do not shower or bathe for at least 24 hours after your operation.
• Bathe in plain water only, do not use perfumed products or talcum powder.
• Make sure you dry your wound gently and thoroughly.

Once home, rest as much as possible for the remainder of the day.

For the initial few days after surgery the leg should be rested and raised several times a day. It is however vital that you perform your physiotherapy exercises.

You should limit your amount of walking for the first few days and gradually build this up.

Physiotherapy

• You should not need any walking aids following your surgery; you should get up and try to walk as normally as possible.
• If you are finding stairs difficult, it may be easier, for the first few days if you take one step at a time, going up with your unoperated leg first and down with your operated leg first.

Return to Work

You can usually return to work after 24 hours but this will depend on your occupation.

Driving

• Do not drive a vehicle or ride a bicycle for a minimum of 24 hours.
• Only return to driving when able to comfortably and safely change gear and carry out an emergency stop.
• Contact your insurance company for further details; all policies vary.

 You can start doing these exercise immediately after your surgery although some people prefer to wait until the next day.

Knee Flexion / Extension

Repeat 2 to 3 sets of 10 reps of this exercise. Continue to perform this 2-3 times daily until the movement of your operated leg is equal to the other side.

Passive Knee Extension Stretch

Sitting on a chair, supporting your operated leg on a chair as shown. Let your leg straighten in this position. Remain in this position for 15 minutes to allow the knee to stretch. Slowly bend the knee to take it off the chair. This exercise will assist you to regain full straightening of the knee. Discontinue when you have regained full straightening.
Repeat 1 to 2 times daily.

Static Quadriceps Strengthening

• Sit with your leg straight. Pull your toes back and push your knee straight by tightening the muscles on the front of your
  thigh.
• Hold for 5 seconds – relax.
• Repeat 2-3 sets of 10 reps of this exercise 2-3 times daily.

Quadriceps strengthening

• Sit with a rolled up towel (or pillow) under the knee. Pulling toes up, press the back of the knee into the roll and lift the heel up by tensing the front of the thigh.
• Hold for 5 seconds – relax.
• Repeat 2 to 3 sets of 10 reps of this exercise 2 to 3 times daily.

Straight leg lift (knee strengthening)

• Sit with your operated leg straight. Exercise your straight leg by pulling the toes up, keeping the knee straight and lifting the leg off the bed.
• Hold approx. 5 secs – slowly lower.
• Repeat 2-3 sets of 10 reps of this exercise 2-3 times daily.

Progress onto this exercise when you are able to do it pain free after surgery. This may take up to 6 weeks.

Step up

• Stand in front of a step. Lead with the operated leg and step fully up onto it.  Use your operated leg to lower yourself back down and start again.
• Repeat 10-30 times as able, repeat on the other side.
• Aim to do the same on each side. Do this 2-3 times daily.
  

Follow Up Clinic

• For most patients there is no need for you to return to the Orthopaedic clinic after your surgery.
• However, if 6-8 weeks following you operation you have any concerns regarding your knee, see contact details.

Passing Urine

• It is important that you pass urine as normal after day surgery.
• Sometimes there may be a delay because you have been fasting. If you have not passed urine before leaving day surgery then you should continue to drink plenty of fluids.
• After several hours at home if you still do not pass urine, or have an urge but are unable to do so, seek advice.
  See contact details.

First Aid

• Slight oozing of blood from the wound is not unusual in the first 24 hours.
• If the wound bleeds heavily, lie down, raise the leg on a pillow and apply pressure with your hand for 10 minutes.

Seek advice immediately, using the contact details, if you develop:

• Persistent bleeding
• Severe bruising or swelling
• A high temperature
• A hot red wound
• A foul smell from the wound

GP Letter

You will be given a letter for your GP.

Please hand this into your GP surgery as soon as possible to inform them of your hospital attendance.

In an emergency

In an emergency go immediately to your nearest Accident and Emergency (Take your GP letter, procedure information sheet and any tablets issued by Day Surgery).

If you have any further queries regarding your operation please contact the Day Surgery Unit where you had your operation.

New Victoria ACH (Day Surgery Unit)

• Call 0141 347 8242 8.30am – 8.00pm Monday to Friday.
• Out with these hours, if further help or advice is required, contact Ward 3, The New Victoria Hospital (0141 347 8453)
  Contact NHS 24 Telephone No: (111).

Gartnavel General Hospital (Ward 4C)

• Call 0141 211 3451 8.00am – 7.00pm Monday to Friday
• Out with these hours, if further help or advice is required, contact NHS 24 by calling 111.

Queen Elizabeth University Hospital (Ward 10A/10B)

Call 0141 452 2700 or 0141 452 2730 8.00am – 7.00pm Monday to Friday• Out with these hours, if further help or advice is required, contact NHS 24 by calling 111.

For most patients there is no need for you to return to the Orthopaedic clinic after your surgery and most patients do not need follow up physiotherapy.  

However, if 6 to 8 weeks following you operation you have any concerns regarding your knee, please contact the  physiotherapy team on 0141 211 3452. This phone is not always attended, we will endeavour to call you back within 2 working days.