Every operation involves an injury to the surrounding structures. Tissue is cut through, the joint is restricted in its movement and muscles are thus reduced at the beginning. Healing processes are set in motion by inflammation and promote recovery.
A complete healing of the damaged structures can last up to 360 days. In the following you will find an overview of the individual healing phases. The medical training therapy starts on the 21 days. This training therapy is particularly aimed at building up muscles. You can find more information in the article MTT Medical Training Therapy.
Aftercare
The inflammatory phase (0-5 day) is divided into 2 phases. The vascular phase in the first 48h and the cellular phase from day 2-5. In the first phase of wound healing, the vascular phase, there is an invasion of leukocytes and macrophages into the tissue.
Leukocytes are part of the immune system and macrophages are the waste products of the cell. The cells in the tissue begin to damage the vascular system, which causes oxygen-rich blood to enter the tissue, thereby increasing the PH level and triggering the stimulus for further wound healing. The active macrophages are responsible for the division of fibroblasts into myofibroblasts.
These become necessary for the new formation of the cells. Similarly, collagen synthesis begins for collagen type 3, which is only found in the inflammatory phase. Collagen 3 is primarily necessary for wound closure and forms the basis for further collagen synthesis and especially for the stabilizing collagen type 3.
In these first hours of wound healing, hardly any targeted therapy is carried out. Instead, the patient should be mobilized out of bed and thrombosis prophylaxis and circulation stimulating measures should be taken. In the cellular phase, further myofibroblasts are formed and type 3 collagen continues to close the wound.
The tissue is still slightly resilient. Many sensitive nociceptors are found at the site of the injury, which are particularly sensitive during the course of wound healing. This serves to avoid overloading the tissue.
Pain is an important warning signal of the body. Therefore, in this phase pain should be adapted and moved in a tension-free area in order not to overload the tissue. In the early phase it is important to memorize the contraindications for the patient.
Easy mobilization into abduction, flexion up to 90° and extension are allowed. In addition, the patient should be shown the correct handling in everyday life. Getting up correctly from bed, turning in bed, long sitting should be avoided and putting on shoes is only allowed with a long shoehorn.
Walking on crutches is worked out. At the beginning a 3-point gait will be necessary to have more stability while walking. As a self-exercise, the patient can already be shown how to push through the hollow of the knee and mobilize the hips up to 90° in the supine position.
The proliferation phase extends from 2-5 days. The actual inflammation should now be complete, the number of leukocytes, macrophages and lymphocytes decreases. From the 14th day on, only myofibroblasts are left in the new tissue.
Collagen synthesis and myofibroblast activity is crucial in this phase to further stabilize the wound. The load should take place in the painless and tension-free area. Too early stretching and too intensive mobilisation should still be avoided, as the inflammatory phase is prolonged and a pain memory can develop.
In therapy, attention should be paid to sympathetic damping, which can be produced by soft tissue techniques in the BWS area by the therapist, or as independent heat therapy by the patient himself. This achieves a general relaxation, so that muscular tensions are avoided. In addition, the psyche is important to take into account, and educational discussions and the involvement of the patient in the course of the therapy help to achieve this.
A positive basic attitude helps the tissue to heal. Active mobilization is also on the agenda. The patient moves within the range of permitted movements and the movement should become noticeably better.
In the early phase of the consolidation phase, the gait pattern is changed to a 4-point gait so that walking adapts to the physiological gait pattern. In the later course of the proliferation phase, the supports can usually already be omitted. In physiotherapy, exercises from the PNF, especially the pelvic patterns and gait training, increase.Exercises such as bridging (lifting the pelvis with the legs in an upright position) are developed as a self-exercise.
Slight knee bends with orientation to the chair or bench edge can be performed. The last healing phase lasts from 21-360 days. The fibroblasts multiply and begin to synthesize the basic substance, so that the elasticity of the tissue can improve.
The newly formed collagen is more strongly stabilized and increasingly organized. The collagen fibers become thicker and more resilient and the collagen fibers 3 are slowly converted into type 1 fibers. Myofribroblasts are no longer needed and disappear from the tissue.
Up to the 120th day, collagen synthesis remains highly active and on about the 150th day, 85% of the collagen type 3 has been converted into collagen type 1. The number of fibroblasts decreases steadily during this phase. Movements are finally allowed and the load can be increased.
The therapy is only complete when the tissue can withstand the stresses of everyday life. In this phase of therapy, most patients are sent to rehab or are already coming out. Exercise therapy can include devices from medical training therapy.
An adjustable bicycle can be used as a warm-up so that the patient does not sit in 90°. The treadmill serves as a running training as well as a warm-up. A trainer should be used with the devices from the beginning to avoid wrong movements.
The leg press is one of the most important and unproblematic devices. It trains the back and front leg muscles. The weight should be increased slowly and the execution should be axis-compatible.
Squatting machines are also very effective and suitable for everyday use. It is important to pay attention to a proper execution of the knee bend. The movement should not exceed 90°, the knees remain behind the toes, the buttocks push far back.
Do not relieve tension in the abdomen and back. Exercises on the stepper to work out a proper gait pattern on the stairs are very important. Exercises can be chosen specifically for the supporting leg by placing the affected leg on top of the stepper and slowly moving the other leg down the step.
The eccentric training improves the muscle activity. Alternating steps up and down provide for strength endurance in the hip muscles. Exercises on the abductor and adductor machine can be included very gently after the capsule replacement tissue has formed (after 3 months at the earliest).
Leg extenders and leg curlers are not recommended due to the load on the long lever on the leg in the first weeks. In general, mobilization should not be forgotten. In the meantime, a physiotherapist can make a new assessment of the mobility and, if the values are worse, a therapeutic session can be included. Sports involving jumping and impact loads should be avoided, but sports such as cross-country skiing, swimming and cycling are very beneficial.
