Previous articles and videos relating to the procedure of arthroscopic trochleoplasty can be found on this site. This discussion and video relates to the basic rehabilitation principles for this procedure. The narrative is below the video.
This video is an interview with Dorte Nielsen, who is a specialist physiotherapist from Copenhagen in Denmark. She is the owner of ProAlign Sports Physical Therapy, which is a progressive practice located within one of Copenhagen's largest fitness centers and with state of the art equipment. Pro Align prides itself in rehabilitating injuries quickly and efficiently, and accepts referrals from sports men and women right up to Olympic level.
I was made aware of Dorte during my interviews with Dr Lars Blønd when we were discussing the procedure of arthroscopic trochleoplasty for patients who have had recurrent patellar dislocation consequent on the developmental abnormality of trochlear dysplasia, where the combination of an abnormally shallow groove for the kneecap and a bony lump in the wrong place on the femur bone combine to allow ready dislocation of the kneecap. Dr Blønd dissects and lifts up the joint cartilage in the affected area, reshapes the groove, pares down the bony lump and secures the joint car
Dr Blønd’s arthroscopic trochleoplasty patients are usually discharged the same day and are given a routine to follow at home until they come into Dorte’s clinic after two or three days.
I asked Dorte how the rehab of arthroscopic trochleoplasty differs from patients with other patellar surgery and she explained that the main issue after surgery was the marked swelling (or oedema) from the trochleoplasty as well as pain if the MPFL ligament had also been reconstructed. This MPFL ligament is a stabiliser that is often torn in patients who have suffered patellar dislocations.
She explained that rehabilitation in these arthroscopic trochleoplasty patients is not all that different from most knee patients, focusing initially on regaining full knee extension -
“For me, I look at the signs for when I can proceed and not, and there I go by like a normal kneehab programme. I start slowly with increasing and getting the full knee extension. When they have gained the full knee extension then we slowly increase to the knee flexion, but for me it is very very important that they regain the full extension within the first month . If they haven’t then we will have extreme problems with them gaining their normal gait back. So that is my experience with the whole process. It is not so much the flexion - that will come nice and slowly.”
Regaining extension can be problematic in situations where the knee has not been through its full range of movement for some time, and where it has been maintained slightly bent because of pain or oedema. Failure to walk normally allows the knee capsule at the back of the knee to tighten up, and also the tendons of the hamstrings muscles at the back of the knee become tight.
At their clinic they have a gravity-altering treadmill, where patients can exercise within a special pocket of air that can reduce weight-bearing in increments down to as low as 20% of the normal body weight. Dorte explained -
“and we have the Alter G anti-gravity which is very very helpful in this process because it activates the hamstrings in the walking process so in that way it is easier to get the posterior capsule to relax and the hamstrings to contract normally and not be so tight and then we can get the full extension easier.”
She also talked about weakness of the quadriceps muscle, particularly the part of it called the VMO (or vastus medialis obliquus), and how they use electrical stimulation to get the VMO activated and firing normally again as well as the use of compression legware to keep the swelling down -
“That is my experience with it. And then also we use the electrical stimulation. Actually I just had an interesting case where I was on vacation so the patient was started later than what I would normally do, and she is a little behind in the normal rehab process. We started it this last week and now we are finally seeing the improvement. It has been very interesting because she could not do a straight leg raise whereas I normally would have the patient be able to do it in two weeks. And she couldn’t and she is in the third week right now and now she is starting to be able to do it after we have activated the VMO and getting rid of some of the oedema.”
“Also we have had a lot of communication about the compression, because I think that it is very important that they have the compression on at all times after surgery. That means also a compression sock, and then they have the compression bandage around too. And they have it on all times except when they are doing the exercises. Because it has a tendency to swell a lot and the swelling limits their range of motion. It would also increase the pain and pressure on the nerve endings, thereby there would be more limping and they would use their crutches longer. If we get the swelling out of the joint easier with the compression, then we will get the range of motion faster too. And we will increase the circulation by having them on a stationary bike. We just slowly sit them and do like oscillations on the bike - so they are not pedally around because then can’t do that yet - but with a high seat , and then just sitting there moving the pedals a little bit back and forth. And then on the anti-gravity machine also to get them onto a decreased weight bearing so that we can normalise their gait easier, and they feel safe.”
Dorte explained how closely they keep in contact with the patient’s surgeon -
“I would think that we have about 50% knee problems - lower extremity problems. Primarily I work closely with Lars Blønd, and there are other knee surgeons who also refer patients to us, but primarily we have all of his trochleoplasty patients here and have a very close correspondence with him every day when the patient has been here. We correspond with him about the procedure, and when to increase or decrease and if there are any problems. Also when things are going really well, we videotape it and mail it to him so that he knows what is going on with his patient. So we have a very close correspondence with the surgeons here.”
“He is very very good at responding quickly. I know if I write him and he is by the computer I will get a fast answer which is better for the patient because then I can adjust my treatment that day, and I won’t have to wait three or four days which is a long time in rehab. And not all therapists are good at responding fast, and not all doctors are that great at it so I think it is important that you have a good team around you that can be the best for the patient. And you take that extra time every day to do it - that’s also key.”
I really think that this kind of close relationship between patient, surgeon and therapist is very important in any kind of surgery, but critically important in knee surgery where the rehab situation can change quite rapidly.
I would like to thank Dorte Nielsen for her time with me today. Her contact details can be found on the KNEEguru website, including the clinic address and her LinkedIn profile.