back to course
Orthopedic Surgeries: Repair to Recovery
This course is protected by U.S. copyright laws. Coping of ANY files on this site is absolutely prohibited. This course is intended for licensed health care professionals. By checking the box below, you agree to terms and conditions specific to this course.
 

Image

Introduction:  Orthopedic Surgery

There are many types of surgical specialties in the medical field. For this course we are going to focus on the surgery that acupuncturists will encounter most often, which is orthopedic (dealing with the musculoskeletal system).

We can generalize surgery into two types: open procedures and arthoscopic or laproscopic procedures. An open procedure typically requires a long incision (>1 inch long) to gain access to the target tissue of the surgery. Open procedures have been around since the beginning of surgery and are still used today for cases where the object being taken out or put into the body is large or if the physician needs to visualize a larger area during surgery.

Arthroscopic and laproscopic surgeries are types of minimally invasive surgeries (MIS). The arthroscopic techniques are used more around the joints whereas laproscopic techniques are used for the internal organs. Both techniques require multiple small incisions (~1/2 inch) into the skin. These incisions are known as ‘portals’ and allow the physician to insert a small camera, tools to remove or repair tissue, and drains to clear out fluid that is pushed into the area during surgery. Because there is less damage to the surrounding tissues, these procedures tend to recover more quickly. Some procedures, such as the ACL reconstruction that we will discuss later, utilize a combination of arthroscopic techniques and open procedures.

Infection

Infection is the main concern following any surgical procedure. All patients are at risk for infection until the incisions from the surgery are completely healed.

Direct contact with the wounds prior to this stage of healing is not recommended.

The acupuncturist should be aware of any signs of infection following a surgery. Pus coming from the surgical site, red streaks extending from the area, foul smell, severe heat in the area, a dramatic increase in tenderness in the area, or extreme fatigue may all indicate an infection in the first weeks after a surgery. Should there be any signs of infection, it is important to contact the surgeon immediately.


SIGNS OF INFECTION
Pus
Red streaks extending from surgery site
Foul odor
Severe heat in the area
Dramatic increase in tenderness in the area
Extreme Fatigue
Image

How Tissues Get Damaged Leading to Surgery

There are four main target tissues for orthopedic surgery: bone, tendon/muscle, cartilage/joint, and ligament. How these tissues become damaged is important for understanding the surgeries to repair them and how to care for the patient after surgery.

Bone injuries are commonly caused by a single large stress to the bone, causing fracture. Depending on the location, severity, and complexity of a fracture a surgery may be required to repair the bone. The two common types of fracture repairs are Open Reduction Internal Fixation (ORIF, where the metal that holds the bone stable is inside the body) and Open Reduction External Fixation (where the metal that holds the bone stable is outside the body, like a halo with pins).

For muscle/tendon, cartilage/joint, and ligament injuries, we can divide the damage origins into two types: trauma and overuse. A traumatic injury is something that happens one time and is not likely to happen again. Examples of traumatic injuries are rolling your ankle while hiking which damages a ligament or an Achilles tendon rupture that occurs when someone steps down from a curb at an awkward angle which tears the tendon in two. These are rare occurrences that we would not expect to have happen in a patient multiple times, meaning re-injury is unlikely.

Overuse injuries are very common in modern society. An overuse injury can be described as a repeated strain to a tissue that occurs in high enough frequency or large enough intensity that the body does not have sufficient time to repair itself before the strain occurs again. This typically leads to a slow degeneration of the tissue. Even though patients may recall a specific moment they first felt the injury, this is commonly the moment where ‘the straw broke the camels back,” or when the damage finally became severe enough to trigger a pain signal. Examples of overuse injuries are the wearing away of cartilage due to bad posture or tendonitis in the elbow due to excessive computer use.
Image

Review of Shoulder Joint Movements

Before we start our first joint, the shoulder, we want to review the specific range of motion for each joint. The following is a concise review of the movements and the muscles involved in the shoulder joint. We recommend printing this chart and placing it in your office for easy reference.


Joint Movement: SHOULDER Plane of Movement Muscles Responsible
Flexion Sagital Anterior Deltoid
Extension Sagital Posterior Deltoid
Abduction Coronal Deltoid
Adduction Coronal Latissimus Dorsi
Internal Rotation Transverse Subscapularis
External Rotation Transverse Supraspinatus, Infraspinatus, Teres Minor


















Image

Shoulder Surgeries

Shoulder surgeries are very common in orthopedics.  There are three main types of surgeries that we will cover for the shoulder: debridement, repair, and replacement.

Shoulder debridement
Shoulder debridement is an arthroscopic procedure where the surgeon removes a loose flap of tissue (like a piece of the rotator cuff, cartilage, or labrum) in order to reduce pain and restore function. I like to compare these to a hang nail - the tissue will not heal on its own, therefore trimming the tissue can prevent further tearing or damage. Patients undergoing debridement surgeries typically recover very quickly with full activity expected in 4-6 weeks. Patients are encouraged to not ‘push through the pain,’ meaning to not do any movements or activities that cause pain in the shoulder. Early pain-free range of motion (ROM) is encouraged as well as the "pendulum exercise" as a safe method to increase circulation and decrease pain (see image).


Cryotherapy (icing) is encouraged multiple times per day to control pain and inflammatory responses. Anti-inflammatory medications and pain medications will be used at the surgeon's discretion. A chart of common shoulder debridement procedures is listed below.

TYPE OF PROCEDURE DESCRIPTION
Rotator Cuff Debridement Trimming away frayed pieces of the rotator cuff tendons, typically supraspinatus tendon or biceps tendon
Acromioplasty or Sub-acromial Decompression The inferior portion of the acromion process is shaved away to created more space in the subacromial area. This prevents additional damage to the rotator cuff and biceps tendon.
Distal Clavicle Resection The lateral joint surface of the clavicle is shaved down to decrease the pain associated with Acromial-Clavicular joint arthritis.
Labrum Debridement Loose pieces of the labrum, or any fraying of the tissue, are removed





Image

Open Shoulder Repairs

Open procedures in the shoulder include rotator cuff repairs, labrum repairs, and biceps tendon repairs. A rotator cuff repair is a common procedure with 200,000 performed in the U.S. annually (Yamaguci, 2011). The surgery entails drilling small screws (“anchors”) into the humerus and using suture wires that attach to the screw to hold the torn pieces of tendon together. These procedures require immobilization of 4-6 weeks in a sling to allow time for baseline healing. Passive ROM exercises can be performed at the surgeon’s discretion for the first 4-6 weeks then progressing to active assisted ROM exercises. Strength exercises are not recommended until 8 weeks out post-operatively. Shoulder internal rotation (IE hand behind the back) should be avoided for the first 8 weeks. During the first 3 months, rolling onto or lying on the post-operative shoulder should be avoided. The shoulder should be 80% as strong as the opposite side at 6 months post operation.

Biceps tendon repairs are similar to rotator cuff repairs and should follow the same post operative restrictions.

Labrum repairs also require suture wires and anchors but the labrum tissue is tied down to the glenoid portion of the scapula, commonly referred to as the socket. This procedure commonly requires sling use for 3 weeks after surgery. The ROM should be restricted to the following measures for the first 8 weeks: 140 degrees flexion, 40 degree external rotation, and no hand behind the back movements higher than L1. Full ROM is expected by week 10 but NO SOONER. Moving the arm too quickly can damage the labrum and the L.Ac. should be aware of the current motion numbers before moving the arm during treatment.



Image


Shoulder Replacement

Shoulder replacement is indicated for severe osteo-arthritic degeneration of the gleno-humeral joint in the shoulder. The two common types of shoulder replacement are Total Shoulder Arthroplasty (TSA) and the Hemi-Arthoplasty (HHA). Shoulder replacement recovery begins with protected ROM and tissue healing. All activity for the first 6 weeks post operation should be passive (the patient does not lift their own arm). At week 6 the patient should have passive ROM of: 140 degrees flexion, 120 degrees abduction, and 60 degrees external rotation. At this time active stretching and strengthening exercises can begin. A complete return to activity is expected by 6 months after the surgery.

Are you taking this course for NCCAOM credit? If so, please follow this link to your first worksheet question. You do NOT need to fill out any worksheet questions if you are taking this course for California CEU credit:
Question #1



Image

Spotlight on Rotator Cuff Injuries:  From the Physical Therapist's Desk

Rotator cuff injuries are a common injury for many health care practitioners. Understanding the mechanisms of injury can help in developing a treatment plan to prevent the injury from returning at a later date or effecting the contralateral side.

Rotator cuff injuries are typically caused by shoulder impingement, where the head of the humerus (aka ‘ball’) translates superiorly in the glenoid fossa (aka ‘socket’) and then collides with the underside of the acromion process. The tendon of the supraspinatus muscle—one of the 4 rotator cuff tendons—typically lies on top of the head of the humerus. When impingement occurs, the soft tendon is mashed between the head of the humerus and the acromion process, causing damage. Over time this leads to fraying and eventually tearing of the rotator cuff tendon.

One of the leading causes of impingement is poor posture—a specific pattern called "forward head posture" (see image below). In this position, the scapula protract, or round forward. This movement is commonly linked to spasm or restriction in the pectoralis muscles. When the scapula protract, shoulder impingement occurs. Thus, posture is a key factor in the prevention and treatment of surgical and non-surgical rotator cuff injuries, especially for patients that have sedentary or computer-based jobs.
Forward Head

Acupuncture Protocols: Rotator Cuff, Biceps Tendon Repair, Labrum Repair, Shoulder Replacement
-contributed by Monica Kaderali, L.Ac.


As you have just learned, post-operative requirements for the shoulder vary by surgery. For a rotator cuff or biceps tendon repair, the patient's affected arm needs to be completely immobilized in a sling for nearly 6 weeks. Labrum repairs have a little less restriction as they require a sling for 3 weeks. During this time distal points on the channel are good to reduce inflammation, release heat, and free the smooth flow of qi.
Dr. Tan's balance method (or any other method that does not needle the injured joint) are a good bet at this time as well.

Once the patient has graduated onto strength training exercises with their physical therapist, it would now be appropriate to perform local needling. The treatment principle is to move qi and blood to get rid of stagnation. You can also needle the scar, as the loosening of the scar tissue will decrease stagnation and free the flow of qi.

For rotator cuff, biceps tendon repair, or labrum repair, the following points are helpful:
Distal: SI 3, LI 4, SJ 4, LI 11, Shenmen, shoulder points on ear
Local: SI 10, SI 11, SI 12, GB 21, SJ 14, ST 14, ST 15, LI 16, extra points Jian Nei Ling and Dai Jian Zhen, KID 27

Shoulder Replacement
For the first 6 weeks post-replacement, the patient is limited to passive ROM exercises only. Distal points to reduce inflammation and stagnation are fine. After 6 weeks the patient usually begins strength training exercises which is a great time to start local needling.







Image

Hip

Below is a review of the hip joint's movements and the muscles responsible.  We recommend printing this page and placing it in your patient's chart for a quick reference.



Joint Movement Plane of Movement Muscles Responsible
Flexion Sagital Rectus Femoris, Iliopsoas, Sartorius
Extension Sagital Gluteus Maximus
Abduction Coronal Gluteus Medius and Minimus
Adduction Coronal  Adductor Brevis, Adductor Longus, Adductor Magnus, Pectinius
Internal Rotation Transverse Adductor Longus, Adductor Brevis
External Rotation Transverse Piriformis, Sartorius





Image

Hip Surgeries

Hip surgeries are less common that knee surgeries. The most common hip surgery is a Total Hip Replacement (332,000) which is much less common that a Total Knee Replacement (719,000). Other hip surgeries include newer, less invasive surgeries such as the Femoral Acetebular Impingement (FAI) surgeries that remove bone spurs and repair the labrum in the hip socket. Hip surgery rates are higher in women than men and higher in Caucasians than African Americans.

Image

Total Hip Replacements
   
Total hip replacements (THR) are effective methods to decrease pain associated with cartilage loss in the hip to due osteoarthritis. In the procedure the head of the femur is removed and the bone is prepared to anchor the new joint surface. In the classic THR, the femur is reamed out to create a space for the long metal anchor, as in the image to the left. The acetabulum is also shaved down to accept the replacement hip socket. The metal pieces in both the femur and the acetabulum will take weeks to have bone grow into their porous or dimpled surfaces. During this time dislocation of the THR is a concern. For this reason post operative precautions should be followed to prevent dislocation.

These precautions should be followed for at least the first 8 weeks after surgery and until the surgeon has lifted the limitations:


No flexion past 90 degrees
No femoral adduction across mid-line
No pivoting on the surgical leg
No sitting with legs crossed
No hip extension













Postoperative Precautions for Total Hip Replacement

It is vital for an acupuncturist to know how to position a patient on the treatment table who has just had a total hip replacement.  The following diagrams are examples of how to and how NOT to position them:


Image

Proper Positioning Post-THR

For the first 6 months after surgery, laying on a treatment table may be uncomfortable. A small pillow or bolster under the knees when lying supine, a pillow between the knees when side-lying, and a pillow under the stomach and pelvis when prone will all increase comfort for your patient. I recommend avoiding lying on the side of the surgery until it is allowed by the surgeon and is comfortable for the patient. Here is an example of a good position for a post-hip surgery.


Acupuncture Protocols Post-Hip Surgery
-contributed by Monica Kaderali, L.Ac.


In the past, hip replacements were done in someone's 6th, 7th or 8th decade. Increasingly hip replacements are being performed on a younger population, a population more likely to have had experience with acupuncture and seek post-surgery treatment.

Keep in mind hip post-surgical precautions regarding positioning and range of motion. Side-lying on the unaffected side with a pillow between the legs is fine, or on the back with pillows underneath the knees as illustrated in the diagrams and photo on page 10 and 11.

For joint replacement surgeries, the patients are sent to physical therapy almost immediately to begin range of motion. This means you can also begin treatment almost immediately as well.

The hip replacement incision will be about 6 inches on the anterior, lateral, or posterior hip. In a posterior incision, the piriformis, gemelli and obturators (deep external rotators) will be cut through. For a lateral incision, the gluteus medius and minimus will be cut through.
The anterior approach cuts between the TFL and sartorius. Many surgeons prefer an anterior/lateral approach, which goes between the TFL and glut medius. When muscles are cut into, they become somewhat "paralyzed" and atrophy quickly sets in. Needling the traumatized muscles and using electrical stimulation can help the muscles begin to fire again, restoring function and strength. Scar therapy is fine to reduce inflammation and speed healing.

To begin treatment, you can use a combination of source and luo points (KID 3/UB 58, LIV 3/GB 37, SP 3/St 40) or 8 Extra coupled points. The Dai Mai is an obvious choice (GB 41, SJ 5).

Point Suggestions:
- GB 30 to open up the channels of the UB and GB.

- UB 31 and UB 32
- Huatojiaji points of L5
- Motor point needling: gluts, piriformis, TFL.
Distal points:
- If the incision is more lateral, choosing one or several GB points like GB 31-34 and GB 40 to alleviate pain and relax the sinews.
- If the incision is more anterior, distal points on the Stomach channel can be used like ST 34, 36 and 41.
- For atrophy of surrounding muscles of the knee, the point combination ST 33 and GB 31 is helpful.

Unlike the shoulder, our hips are connected together by the pelvis and rely on each other's proper functioning to have a smooth, controlled gait. For this reason, it is important to treat the unaffected hip, being cautious about positioning and foregoing several important points for the time being (GB 30, huatojiai, and UB points). In a supine position, you can still access the hip stabilizers and treat the IT band, TFL, glut medius and minimus and distal leg points like GB 34 and ST 36.


Image
Joint Prosthesis 101 (everything you wanted to know but didn't know who to ask)
- contributed by Monica Kaderali, L.Ac.

Knee or hip replacement joints are made of metal, ceramic, plastic or a combination therein and are referred to as a prosthesis.  They replace part of or the entire joint.  These artificial joints have a lifespan of about 15 years, so patients will need a secondary surgery down the road.

The most commonly implanted metals used in orthopedic implants are cobalt/chrome, stainless steel, and titanium. All orthopedic implants are alloys, meaning they are a combination of different metals.  Metals often included in orthopedic implant alloys include nickel, aluminum, and others.

How do the prosthesis stay in the body? 
The parts used to replace the joint come in two general varieties: cemented and uncemented.
Cemented parts are fastened to existing, healthy bone with a special glue or cement (literally). Uncemented parts rely on a process called biologic fixation, which holds them in place. The parts are made with a porous surface that allow the bone to grow into the pores of the implant to hold the new parts in place. Sometimes a doctor will use a combination of cemented and uncemented techniques, called a hybrid replacement.

Why do some artificial joints fail?
The devices are expected to last 15+ years.  Device longevity can depend on personal factors, such as activity level (more active means more wear), bone density (low bone density will loosen devices quicker), as well as location (weight bearing devices dont last as long as upper extremity devices.) 

Sometimes it is due to improper design or incorrect placement by the surgeon.


Mostly, however, it is due to the debris caused by the shedding of metal and polyethylene particles into the surrounding tissue causing inflammation and eventual bone loss, which leads to the prosthesis loosening.  Debris from the prosthesis also causes high blood levels of metal and metal toxicity.

Other causes of hip replacement failure include fracture (of the bone connected to the implant), dislocation, infection around the implant, and poor cementing technique.

Revision surgery (to correct a loose prosthesis) is generally more difficult and takes longer to perform than the initial hip replacement.

Prosthesis Recall
Many artificial joints begin to corrode or malfunction at a much faster rate than the expected 15 years.  This usually causes a recall, and a recall’s inevitable aftermath, a class action law suit.  The companies DePuy, Zimmer Holdings, Biomet Hip, Wright Medical, Stryker and Trident have all manufactured artificial joints and have had recalls, whether voluntary or mandatory.  Certain companies have set up funds to compensate patients who have suffered from their implants.  Scan daytime TV ads and there are plenty of advertisements for joint recalls sponsored by law firms.

Immune Reactions to Hardware
Many people have known skin sensitivities to various metals, the most frequent being nickel found in inexpensive jewelry. Some orthopedic implants contain small amounts of nickel, and there has been concern that this may be an issue for those individuals receiving implants who also have skin irritation from this metal.

Implant degradation has been shown to be associated with dermatitis, urticaria, and vasculitis.  Sometimes cutaneous signs of an allergic response appear after implantation.  In other words, the skin surrounding the joint that was replaced gets red or itchy. 

What are symptoms of joint implant problems?
For the hip, thigh pain is the primary symptom of stem loosening, especially during walking.  The pain often radiates to the knee.
General symptoms of joint implant issues are:
- Regular or prolonged pain
- Swelling near the joint especially when combined with skin redness or heightened temperature in the area
- Limping, change in walking ability
- Stiffness that is not associated with a marked increase or decrease in physical activity
- “Squeeky” noises in the joint
- Joint "giving out"

- Fractured bones

Resources
http://www.niams.nih.gov/Health_Info/Hip_Replacement/

http://www.ori.org.au/hipjoint/failing.html

Hallab N, et al. "Metal sensitivity in patients with orthopaedic implants" J Bone Joint Surg-Am 2001; 83-A: 428-36.
Image

Knee

Below is a review of the knee joint's movements and the muscles responsible.  We recommend printing this page and placing it in your patient's chart for a quick reference.


Joint Movement:  Knee Plane of Movement Muscles Responsible
Flexion Sagital Biceps femoris, semitendinosus, semimembranosus
Extension Sagital Rectus femoris, Vastus lateralis, Vastus medialis, Vastus intermedius
Image

Knee Surgeries

Knee surgeries are very common with over 900,000 arthroscopic and 600,000 knee joint replacement surgeries performed annually in the U.S.  Arthroscopic procedures in the knee are used to take out scar tissue, remove loose pieces of cartilage, ligament, or meniscus, shave away roughened pieces of cartilage, or lengthen the iliotibial band (in the lateral retinaculum).

Menisectomy vs. Meniscus Repair
For many health care providers, there is confusion in the difference between the common menisectomy (removing a small portion of the meniscus) and a meniscus repair (using anchors and wire sutures to repair a section of the meniscus). While their names are similar, the timing of their outcomes is very different. Menisectomies, as well as debridement to remove scar tissue and small tears in the ligaments and cartilage, progress quickly with the patient back to full activity by 6 weeks post surgery. ROM can progress as the patients pain allows. You can identify these arthroscopic procedures by the two scars on each side of the patellar tendon that are less than 1 inch long.  Meniscus repairs are a more rare procedure that requires stitching the two torn pieces of meniscus together using a suture attached to the tibia. Meniscus repairs take about 4 months to recover from, primarily due to the slow recommended ROM and strength gains after the procedure.


Are you taking this course for NCCAOM credit?  If so, please follow the link to the second worksheet question:
Image

ACL Ligament Reconstruction

Some surgeries require a combination of arthroscopic and open procedures, including ACL ligament reconstructions. In this procedure, a new ACL (harvested from either the patient's own hamstring or patella tendon or a donor graft from a cadaver) is fed through a small hole drilled into the tibia. For this to occur, a small open procedure is done on the proximal portion of the tibia which gives this surgery its characteristic 2-3 inch long vertical scar on the proximal tibia. The arthroscopic surgery—which produces the two smaller incisions near the patellar tendon—is used to guide the new ACL through the joint. In order to protect the new ACL repair, a long leg brace is used for the first weeks after surgery. This brace should be kept on at all times except bathing until the surgeon allows the patient to function without it. Following the long leg brace, the surgeon may or may not have the patient wear a sports brace. Following the ACL surgery, no activity outside of the long leg brace and only ROM exercises are encouraged for the first 4-6 weeks. ROM will be limited and should only increase without pain by the patient and per the surgeon's recommendations. Strengthening exercises can begin around 4-6 weeks at which point the Acupuncturist should be able to continue their treatments without restrictions. Most ACL reconstructions return to full sports within 8-9 months after surgery.
Image

Knee Replacement

In a total knee replacement, the distal end of the femur and the proximal tibia are removed via an open procedure. The femoral end is replaced by a metal portion that has a long anchor that extends upwards into the femur and the tibial portion is replaced by a metal platform with a plastic plate attached. This procedure has a long vertical incision. ROM is encouraged immediately after surgery and the patient may walk with an assistive device. The first 4-8 weeks of rehabilitation focuses on the inflammation control and restoration of motion. During the surgery many of the supporting ligaments in the knee are cut and the shape of the knee replacement surfaces helps to regain some of the stability that the ligaments provided. Due to this shape, though, most knee replacements will not get more than 125 degrees of bending. The knee should fully extend after a knee replacement. Most patients will be able to ride a bike when they achieve 110 degrees of knee bending. Restoration of strength, balance, and normal gait should occur by 4-6 months post operatively. Some patients may complain of a deep aching type of pain for up to one year after a knee replacement.
Image

Spotlight on Knee Surgeries:  From the Physical Therapist's Desk

This is a good time to talk about knee extension. Keeping a knee fully straight after surgery is often painful for the patient. They may prefer to keep a pillow under their knees during treatment or while sleeping at night. However, they must not sacrifice a good surgical outcome for this temporary comfort. Keeping a knee straight is very important to limit a joint contracture after EVERY knee surgery. Always encourage your patients to keep the knee straight at all times after surgery until they are fully healed.
Image

Acupuncture:  Menisectomy, Meniscus Repairs, ACL Reconstructions
-contributed by Monica Kaderali, L.Ac.


When treating your patient post-knee surgery, be careful to pay attention to the patient’s positional restrictions which vary according to type of surgery.  Lowering the table will help facilitate getting on and off.  Using a chair and propping the leg up on another chair or bench is another option.

Like menisctomies and meniscus repairs, ACL reconstructions have the two small incisions on each side of the knee.  These incisions roughly correspond to ST 35 and Xi Yan.  These small incisions generally fade quite well.  Needling these points will help reduce the possibility of scar adhesions leading to tendonitis or patella issues down the road.  ACL reconstructions also have a vertical 2-3 inch scar.  There is little flesh under this scar, as it goes directly over the patella (see image). Because there is little flesh this scar is prone to aggressive adhesions with the underlying tissue, which create challenges to their recovery as well as aesthetic concerns.  Treating the scar can bypass some of these potential issues.  For all post-op knee conditions, the treatment principle is to reduce heat and inflammation and swelling, move qi and blood, and tonify qi and blood to promote healing.  Light moxa on the knees will speed recovery and reduce pain.

Depending on the type of surgery, here are some point suggestions:
Distal:  St 41, GB 40, Kid 3, Kid 6
LIV 3 and GB 37, Source/Luo of Liver and GB
KID 3 and UB 58,  Source/Luo of Kidney and UB

Local:  St 35, Xi Yan, Heding, SP 8, SP 9, Sp 10,
St 34, ST 36, Kid 10, LIV 7, LIV 8
GB 31, GB 33 & GB 34

Helpful point combinations: 

For difficulty in flexing and extending the knee:  ST 34, LIV 8, GB 33.
Stiffness and pain in the knee:  ST 34, SP 10, Xi Yan, GB 34 and SP 9.
Numbness in the knee:  St 35, St 31, GB 34

Knee Replacement
Many patients are encouraged to do range of motion exercise immediately; in fact some begin from the moment they wake up from their surgeries in their hospital beds by way of a Constant Passive Motion machine.  This means you can also begin your acupuncture treatments as soon as possible to reduce inflammation, restore qi and blood and proper muscle functioning.

A good starting protocol post-knee replacement specifically for redness, swelling, and pain of the knees is ST 36,  ST 33,  and LIV 7.  As they begin to heal, choosing any of the above points is fine.

Joint replacements place major trauma on multiple tissues and structures.  Each patient will respond differently post-surgery.  For some treatments, moxa might be all they need.

 
Image

Spine

Below is a review of the spine's movements and the muscles responsible.  We recommend printing this page and placing it in your patient's chart for a quick reference.


Joint Movement:  Spine Plane of Movement Muscles Responsible
Flexion Sagital Rectus Abdominus, Obliques (lumbar), Longus capitus, longus calli (cervical)
Extension Sagital Erector Spinae
Side Bending Coronal Quadratus Lumborum (lumbar), Upper Trapezius, Scalene (cervical)
Rotation Transverse Transverse Abdominus (lumbar), Sternocleidomastoid (cervical)

Spine Surgeries

Spine surgeries typically occur due to compression on the spinal cord or nerve roots. Many of these procedures are open procedures, such as fusions, laminectomy, foramenotomy, and disc replacement. The microdiscectomy procedure uses a small camera system which allows the physician to observe the inner structures similar to an arthroscopic procedure. The figure below will give a brief understanding of each procedure:


 SURGERY TARGET TISSUE POSTOPERATIVE INSTRUCTIONS
 Fusion Degenerative discs, arthritic spine.  Fusion maintains the joint spacing to allow nerves to function. First 4 weeks:  no lifting over 5 lbs, no sitting >20 min, no household chores.
 Laminectomy Nerve compression from disc or bone spur, removing the lamina reduces the compression First 2 weeks:  no lifting over 5 lbs, no sitting >20 min, no household chores.
 Foramenotomy Removal of bone material from the foramen to decrease nerve compression  First 2 weeks:  no lifting over 5 lbs, no sitting >20 min, no household chores.
 Microdisectomy Removal of disc material to decrease compression on the nerve root or spinal cord No driving for first 2 weeks.  May return to light work at 3 weeks and light recreational activities at 3 months.
Disc Replacement Removal of degenerative disc and replacement with combination of metal and plastic.  Can only be used at certain spinal levels. No driving for first 2 weeks.  May return to light work at 3 weeks and light recreational activities at 3 months.
 Rhizotomy Use of radiowaves to deaden the nerves that innervate the facet joints Return to activity 1 day post- procedure.





Image

Fracture Repair

Fracture repair can be very difficult to generalize. We like to say, “Traumatic fractures are like snowflakes, no two are alike.” Indeed, the location and severity of the fracture, as well as the health and activity level of the patient, will have a major impact on the decision making on fracture care. If a fracture is stable and does not require surgery, the physician will typically require 8 weeks of no strain being placed on the bone—typically achieved by casting or slings--followed by a slow return to normal function. There should be no long term limitation following this type of case.

Should the patient require surgery, any of the following may be used alone or in conjunction: plates (metal pieces on the outside of the bone), pins (smooth metal nails), screws, or wires. These procedures are typically referred to as “internal fixation” with hardware. One of the benefits of this type of procedure is that the patient can put pressure on the bone sooner than if the surgeon chose to cast the area. The rehab timelines following internal fixation can vary and care should be given to not place any strain on the bone until cleared to do so by the surgeon.

Occasionally a fracture will be so severe and unstable that it requires an ‘external fixation’. This procedure involves placing a number of pins through the skin and into the bone. These pins will then connect to a number of metal ‘halo’ rings and bars that can hold the bones in a proper alignment. These procedures are very prone to infection and care should be placed to avoid contamination of the area. I recommend avoiding direct treatment to the area until the pins have been removed and the wounds have healed. 
  
Image

Postoperative Care for Spinal Surgeries

Of particular concern for acupuncturists treating a patient with a recent spine surgery is proper positioning on the treatment table. These patients will be sensitive to tension on the spinal column. We recommend that when supine, a bolster is kept under the knees and a towel roll is kept under the neck as well as a pillow. When prone, 1-2 pillows underneath the waist, a pillow under the ankles, and a towel roll under each shoulder will help the spine stay in as little tension as possible. The incision area for the surgery may be tender to pressure and will require additional attention.

Are you taking this course for NCCAOM credit?  If so, please follow this link to your last worksheet question:
Question #3





Acupuncture Protocol Post-Spine Surgery
- contributed by Monica Kaderali, L.Ac.

A person elects to have spine surgery due to nerve compression issues.  Post-operative restrictions are for 2-4 weeks for activities of daily living and 3 months for light, recreational activities.  In laminectomies, foramenotoies, or microdesectomies a target tissue is removed in order to make space for the nerve to flow freely without obstruction.

Fusions are different from the rest of those procedures in that hardware is installed to keep segments from having any motion, in effort to maintain joint space for the nerve.  It is done by fusing the joint in a position that doesn't allow for the space to move.  It is often done in conjunction with one of the other procedures that remove tissue to create space, but then the fusion is done to hold it. 

Disc replacement patients differ in that instead of just removing an obstructive structure, hardware is put in to replace the structure, which makes it like a joint replacement.

The Du channel is an obvious choice for spinal surgeries. 
At the very least, using the master and couple points is useful (SI 3, UB 62).  Often, however, scar tissue prevents using this important channel.  Working on the scar will influence the Du channel and help significantly with recovery time and reduce adhesions allowing a little more give.

Huatojiaji points are useful for any type of spine surgery.  A cushion of two points up and two points down from the spinal segment in question is a good idea.  Inner and outer bladder points will address muscle and tissue trauma from surgery.  The spine relies on proper alignment and functioning of each segment to make the entire structure work in optimally.  This is why using distal huatojiaji points or UB points is recommended, to ensure proper qi flow up and down this vital structure. 

Remember, most of these conditions initially presented with neuropathy.  Even if the surgery resolves the neuropothy, meridian treatment can still address the path of the original neuropathy. 

For example, if the patient has a fusion of L4-L5, a point protocol could be:
SI 3/UB 62
Huatojiaji of L2-S1
UB 23, 24
Huatojiaji of C2,C3
scar therapy




Image
Screws, Washers, Nails, Oh My!
- contributed by Monica Kaderali, L.Ac


Orthopedic surgeons use hardware like screws, plates, wires, washers, pins, rods, and nails to fuse together bones from fractures or to correct conditions like severe scoliosis.  Implanted metal can help broken bones heal properly, however they do not help the bone heal any faster.

Hardware is not necessarily removed once the bone has fused together, but only in cases of severe pain coming from irritation from the implant on surrounding tissues.  Sometimes the pain does not go away once the hardware is removed.  Hardware removal surgery is costly and may lead to complications such as neurovascular injury, refracture, recurrence of deformity or infection.

For fascinating x-ray images of joints with hardware, check out the excellent article “Orthopedic Hardware” found at:  http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/orthopedic-hardware

Resources
Busam ML, et al. "Hardware removal: indications and expectations" J Am Acad Orthop Surg. 2006 Feb;14(2):113-20.

Brown OL, et al. "Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures." J Orthop Trauma. 2001 May;15(4):271-4.
Image

Conclusion

With an advanced understanding of the precautions and healing times for orthopedic surgeries you will know how to manage these cases better in your own practice. In addition, your newly gained understanding of orthopedic surgeries will allow for better communication with Western medical practitioners, such as surgeons and physical therapists.
 

 
 
 
 
Login | Register