Pa Tell Ectomy

PATELLECTOMY

INTRODUCTION

Patellectomy is the procedure of surgical removal of patella. Normally it will be performed when the patella is effectively destroyed.E.g. - Smashed in an accident beyond repair or severely damaged by arthritis.

When the patella is removed the extensor mechanism become lax and it may be not possible to ever regain full extension in most of the cases.

A study of twenty patients who underwent Patellectomy found that only around 53% achieved a good result with time, there was a statistically significant increase on radiological changes at the tibiofemoral joint.

A case report of arthroscopic findings in 16knees with a prior Patellectomy should severe medial compartment and trochlear articular damage in patient aged around 22-64 years for the past 3-4years with progression degeneration, these patients may later require a total knee arthoplasty (TKA).

In most of the cases after Patellectomy it was observed that most of the patients are suffering from loss of knee power and its function. Quadriceps weakness and failure to resolve anterior knee pain.

Not all the patellar fractures are amenable to open reduction and internal fixation, in most of cases of patella fractures, one large fragment of patella can be preserved most of the distal pole is comminuted, the superior pole is intact in these types of cases there is no need of Patellectomy.

PATELLECTOMY

Physiotherapy plays an important role after Patellectomy. It will include like aid of crutches a walker and other assitive devices to maintain and improve the overall condition of the patients.

Persistive exercises stair climbing, Single leg support, patellar mobilization, and swimming and during all these is helpful for to keep the muscles strong around knee joint.

Ultra sound also has a role to play in the evaluation of the structures around the knee and it is particularly useful in revealing cysts in the fat pad.

In this way physiotherapy plays an important role after patellectomy.

PATELLECTOMY

ANATOMY OF THE PATELLAE

In addition to the two main bones, the knee also has the accessory patella (Kneecap).

It is a large sesamoid bone in the central bone in the central tendon of the quadriceps muscles.

It is selected infront of the lower end of the femur about 1 cm above the knee joint.

The articular surface, which can have a variable contour, articulates with the trochlear groove of the femur.

Most patellae possess a median ridge that proximal patella into medial and lateral facet.

The medial facet usually is the smaller of the two.

FEATURES OF THE PATELLAE:

The patellae has

An apex.

Three borders,

Two surfaces.

ATTACHMENTS ON THE PATELLAE:

PATELLECTOMY

The superior border (base) provides insertion to the rectus femoris in front and to the vastus intermedius behind.

The lateral border provides insertion to vastus lateralis on its upper two thirds or more.

The non-articular area on the posterior surface provides attachment to the ligamentum patellae below, and is related to the infrapatellar pad of fat above.

OSSIFICATION:

The patella ossifies from several centers, which appear during 3-6 years of age.

Fusion is complete at puberty.

One or two centers at the superolateral angle of the patellae may form separate pieces of bone.

ANATOMY OF KNEE JOINT:

The knee joint looks like a simple joint, it is one of the most complex. Moreover, the knee is more likely to be injured than is any other joint in the body.

We tend to ignore our knees until something happens to them what that causes pain. As the saying goes however, “an ounce of prevention is worth a pound of cure”.

The knee is essentially made up of four bones

The femur, which is the large bone in the thigh, attaches by ligaments and a capsule to tibia.

PATELLECTOMY

Just below and next to the tibia is the fibula, which runs parallel to the tibia.

The patella or what we called as the kneecap rides on the knee joint as the knee bends.

When the knee moves, it does not just bend and straighten, or as it is medically termed flexion and extension.

There is also a slight rotational component in this motion.

The knee muscles, which go across the knee joint, are the quadriceps and the hamstrings.

Hamstrings are on the back of the knee. The quadriceps are on the front of the knee.

The ligaments are equally important in the knee joint because they hold the joint together.

In review, the bones support the knee and provide the rigid structure of the joint, the muscles move the joint and the ligaments stabilize the joint.

CARTILAGES:

The knee joint also has a structure made of cartilage, which is called the meniscus or meniscal cartilage.

PATELLECTOMY

The meniscus is C-shaped piece of tissue which fits into the joint between the tibia and the femur.

It helps to protect the joint and allows the bones to slide freely on each other.

There is also a bursa around the knee joint.

A bursa is a little fluid sac that helps the muscles and tendons slide freely as the knee moves.

MENISCI:

There are 2 types of menisci

1.) The medial menisci.

2.) Lateral menisci.

1.) Medial menisci:

The medial meniscus is nearly semicircular being wider behind than infront.

2.)Lateral menisci:

The lateral meniscus is nearly circular.

The posterior end of the meniscus is attached to the femur through the meniscal femoral ligaments.

PATELLECTOMY

FUNCTIONS OF MENISCI:

1.) They help to make the articular surfaces more congruent.

2.) The menisci serve as shock absorbers.

3.) They help to lubricate the joint cavity.

4.) Because of their nerve supply, they also have a sensory function. They give rise to proprioceptive impulses.

CRUCIATE LIGAMENTS:

There are two cruciate ligaments located in the center of the knee joint.

The anterior cruciate ligament and the posterior cruciate ligament are the major stabilizing ligaments of the knee joint.

THE ANTERIOR CRUCIATE LIGAMENT

It begins from the anterior part of the inter condylar area of the tibia, runs upwards, backwards and laterally and is attached to the posterior part of medial surface of the lateral condyle of the femur.

It is taut during extension of the knee.

THE POSTERIOR CRUCIATE LIGAMENT

PATELLECTOMY

It begins from the posterior part of the intercondylar area of the tibia, runs upwards, forward and medially, and is attached to the anterior part of the lateral surface of the medial condyle of the femur.

It is taut during flexion.

SYNOVIAL MEMBRANE:

Synovial membrane of the knee joint lines the capsules, except posteriorly where it is reflected forwards by the cruciate ligaments, forming a common covering for both ligaments.

In front, it is absent from the patellae. Above the patella, it is prolonged upwards for 5 cm or more as the supra patellar bursae below the patella, it covers the deep surface of the infra patellar pad of fat, which separates it from the ligamentum patellae.

FIBULAR COLLATERAL LIGAMENT:

This ligament is strong and cord like, it is about two inches long.

Superiorly, it is attached to the lateral epicondyle of the femur just above the popliteal groove.

Inferiorly, it is embraced by the tendon of the biceps femoris, and is attached to the head of the fibula in front of its apex.

OBLIQUE POPLITEAL LIGAMENT:

This is an expansion from the tension of the semimembranous.

It runs upwards and laterally, blends with the posterior surface of the capsule, and is attached to the intercondylar line and lateral condyle of the femur.

PATELLECTOMY

It is closely related to the popliteal artery, and is pierced by the middle genicular vessels and nerve, and the terminal part of the posterior division of the obturator nerve.

ARCUATE POPLITEAL LIGAMENT:

This is a posterior expansion from the short lateral ligament.

It extends backwards from the head of the fibula, arches over the tendon of the popliteus, and is attached to the posterior border of the intercondylar area of the tibia.

TRANSVERSE LIGAMENT:

It connects the anterior ends of the medial and lateral menisci.

LIGAMENTUM PATELLAE:

This is the central portion of the common tendon of insertion of the quadriceps femoris the remaining portions of the tendon from the medial and lateral patellar retinacula.

The ligamentum patella is about 3 inches long and one inch broad.

It is attached above to the margins and rough posterior surface of the apex of the patellae and below to the smooth, upper part of the tibial tuberosity.

The superficial fibers pas infront of the patellae, the ligamentum patellae is related to the superficial and deep infepatellar, bursae and to the infrapatellar pad of fat.

RELATIONS OF THE KNEE JOINT:

ANTERIORLY:

1.) Anterior bursa.

PATELLECTOMY

2.) Ligamentum patellae.

3.) Patellar plexus of nerves.

POSTERIORLY:

a.) At the middle.

1.) Popliteal vessels.

2.) Tibial nerve and

3.) Middle genicular vessels and nerve.

b.) Postero-laterally-

1.) Lateral head of gastrocnemius.

2.) Plantaris and

3.) Common peroneal nerve.

c.) Postero medially-

1.) Medial head of gastrocnemius.

2.) Semitendinosus.

3.) Semimembranosus.

4.) Gracilis and

5.) Popliteus.

MEDIALLY-

1.) Sartorius, Gracilis and Semitendinosus.

2.) Great saphenous nerve and vessels.

3.) Semimembranous

4.) Inferior medial genicular vessels and nerve.

LATERALLY:

PATELLECTOMY

1.) Biceps femoris.

2.) Tendon of popliteus.

3.) Inferior lateral genicular vessels and nerves.

BLOOD SUPPLY:

The knee joint is supplied by the anastomosis around it

The chief sources are

1.) Five genicular branches of the popliteal artery.

2.) The descending genicular branch of the femoral artery

3.) The descending branch of the lateral circumflex femoral artery

4.) 2 recurrent branches of the anterior tibial artery.

5.) Circumflex fibular brach of the posterior tibial artery.

NERVE SUPPLY:

1.) Femoral nerve, through its branches to the vasti, especially the vastus medialis.

2.) Sciatic nerve, through the genicular branches of the tibial and common peroneal nerves.

3.) Obturator nerve, through its post division.

PATELLECTOMY

BIO-MECHANICS OF KNEE JOINT

The patellar tendon attaches to the tibial tubercle on the front of the tibia just below the front of the knee.

As the quadriceps muscle contracts it pulls on the quadriceps tendons, the patella, and the patellar the tendon and the tibia to move the knee from a flexed position to an extended position.

Conversely when the quadriceps muscle relaxes it lengthens. This allows the knee to move from a position of extension to a position of flexion injury.

PATELLECTOMY

With out the intact patella tendon, the patient is unable to straighten the knee.

If a rupture of the patella tendon occurs, and the patient tries to stand up, the knee will usually buckle and give way because the body is no longer able to bold the knee in a position of extension.

In some joints, such as the hip the bony structure gives a basic stability but the knee has no such help.

The lower end of the femur divided into two barrel shaped condyles that sit on the two almost flat surfaces of the upper end of the tibia.

The stability and strength of the knee joint therefore, depends on the controlling ligaments to some extent but otherwise entirely upon the controlling muscles.

Without good muscle control the knee is unstable joint, heavily loaded by the body above and vulnerable to injury.

TIBIOFEMORAL ALIGNMENT AND WEIGHT BEARING FORCES:

The anatomical axes of the femur is oblique directed inferiorly and medially from its proximal to its distal end the anatomical axis of the tibia is directed almost vertically the femoral and tibial longitudinal axis normally from an angle medially at the knee joint of 185-190 o.

The femur is angled off vertically 5-10o creating a physiological valgus angle at the knee.

The mechanical axis of the lower extremity is the weight bearing line from the center of the head of the femur to the center of the superior surface of the head of the talus.

PATELLECTOMY

The weight bearing stresses on the knee joint in bilateral static stance is equally distributed between the medial and lateral condyles with out any concomitant horizontal shear forces.Deviations in the normal force

The 1st part of the flexion of femur from full extension (0-25o) is primarily rolling off the femur condyles on the tibia.

As flexion continuous the rolling is accompanied by simultaneous anterior glide just sufficient to create a nearly pure spin of the femur.

Resulting in little linear displacement of the femoral condyles after 25o of flexion.

The anterior glide of the femoral condyle results in part from the tension encounter in the ACL as the femur rolls posteriorly from the tibial condyle.

Extension of the knee from flexion occurs as a rolling of the femoral condyles and the tibial condyle, displacing the tibial condyles.

The tibial condyles act back to the neutral position after the initial forward rolling the femoral condyles glide posteriorly just enough to continue extension of the femur as an almost pure spin of the femoral condyles and the tibial condyles tension in the PCL and the shape of the menisci facilitate the intra articular movements of the femoral condyles during knee extension.

The motion of the menisci with flex and extension are component of the Distribution may be caused among other things by disease in the normal tibio-femoral angle.

If the medial tibio femoral angle is greater than 195o an abnormal condition is called genu valgum.

This condition will increases the compressive force on the lateral condyle.

PATELLECTOMY

If the medial tibio-femoral is 180o or less the resulting abnormality is called genu varum.

In this condition the medial tibial condyle are increases.

The menisci of the knee are important in distributing and observing the large forces crossing the knee joint.

If the menisci are removed the magnitude of the average loador unit area on the articualr cartilage nearly doubles on the femur.

ARTHO KINEMATICS OF KNEE JOINTS:

Flexion/extension:

The large articular surface of femur and the relatively small tibial condyle create a potential problem as the femur begins to flex on the tibia the femoral condyles were permitted to role posteriorly and the tibial condyle the femur would run out of the tibial condyle before much flexion had occur.

This would result in limitation of flexion or the femur would role off tibia motion.

Failure of the menisci to distort in the proper direction can also result in limitation of joint motion, the interposition of the menisci will prominent extension from being completed.

LOCKING AND UNLOCKING MOVEMENTS

PATELLECTOMY

The incongruence of femoral condyles and tibial condyle results in rolling and gliding of the condylar surfaces on each other as the femur extends to about 30o of flexion.

The shorter lateral femoral condyle completes it’s rolling-gliding motion as extension continues the longer medial condyle continues to roll and to glide posteriorly increase in tension in the knee joint ligaments as the knee approaches full extension may also contribute to the rotation with in the joint.

Medial rotation of the femur that accompanies the final stages of the knee extension is not voluntary or produced by muscular forces it is refer to as automatic or terminal rotation of knee joint.

The tibial tubercles are lodged in the intercondylar notch the menisci are tightly interposed between the tibial and femoral condyles.

Automatic rotation is also known as the locking mechanism or screw home mechanism of the knee to initiate flexion the knee must first be unlocked.

Automatic rotation is the locking of the knee occurs in both open chain and chain and closed chain knee joint function.

AXIAL ROTATION:

During axial rotation of the knee joint. The longitudinal axis for motion lies at the medial intercondylar tubercle.

When lateral rotation of the tibia occurs at the knee joint the medial tibial condyles moves only slightly anteriorly the relatively find medial femoral condyle.

In the medial rotation, the direction of motion of the tibial condyles reverses with the medial tibial condyle motion only slightly posteriorly.

When there is rotation between the femoral and tibial condyles the menisci of knee joint maintain the relationship to the femoral condyles.

MUSCULAR FORCES:

PATELLECTOMY

A.) QUADRICEPS FORCE:

The quadriceps femoris is the extensor muscle, it is 3 times stronger than the flexors as can be expected from the fact, that it counteract the effect of gravity.

The effect of gravity the quadriceps as indicated by the name consists of muscles 4 muscle bellies, Which are inserted by a common tendon into the anterior tibial tuberosity.

Three non-articular muscles

The vastus intermecius muscle, The vastus laterlis and The vastus medialis.

Bi-Articular muscle

The rectus femoris.

Three non-articular muscles are exclusively extensors of the knee the medialis is more powerful and extends more distally than the lateralis and its relative predominance is meant to check lateral dislocation of the patella.

The normally balanced contraction of these vasti produces a

resultant upward force along the long axis of the thigh but if there is imbalance of these muscles

E.g. if the vastus lateralis predominates over a deficient medialis, the patella escapes laterally.

This is one of the mechanisms responsible for recurrent dislocation of patella, which always occur laterally.

After patella the force “Q” acts tangentially to the patellar surface of the femur and directly on the tibial tuberosity it can there fore be resolved into 2 vectors Q5, Which the tibia pressed against the femur and Q6 and the component effective for extension.

ANATOMICAL PULEYS FOR QUADRICEPS MUSCLE:

PATELLECTOMY

When the direction of pull of muscle is altered the bone or bony prominence coursing the deflection forms an anatomic pulley.

Pulley changes the direction with out changing the magnitude of the applied force.

The quadriceps femoris muscle acting on the tibia. It shows schematic representation of the action line of the quadriceps with out the patella.

The action line lies paralled to the femur and close to the knee joint axis the moment arm is small shows the deflection of the action line away from the joint axis when the patella is interposed the moment arm is significantly larger.

If the quadriceps femoris muscle controlled with equal magnitude both with and with out patella.

The torque applied to the tibia by the muscle would be much greater with the patella because the force is applied at a greater distance from the joint axis.

B.) HAMSTRING FORCE:

There are lodged in the post compartment of thigh they are the hamstring muscles-

Biceps femoris

Semitendinoses

Semimembranosus.

Hamstring part of adductor magnus.

First three muscles inserted the medial aspect of the tibia.

The hamstrings are at once extensors of the hip and flexors of the knee and their action depends on the position of the hip.

When the hip is flexed at the 40o the relative shortening of the muscles can be partly made up for passive flexion of the knee.

When hip flexion reaches 90o the relative shortening cannot be wholly compensated even by a 90o flexion of the knee as hip

PATELLECTOMY

flexion exceeds 90o it becomes very difficult to keep the knee in full extension.

When the hamstrings are stretched by hip flexion there efficiency as knee flexors increases.

If the hip is maximally extended the hamstrings show a relative lengthening and so they lose some of their efficiency as knee flexors.

PATELLO-FEMORAL MOVEMENTS:

The extensor apparatus of the knee slides on the lower end of the femur like a cable on a pulley.

The patellar surface of the femur and the intercondylar notch effectively from a deep vertical gutter in the depths of which sides the patella.

Thus the force of quadriceps directed obliquely, speriorly and slightly laterally, is turned into a strictly vertical force.

While turning the patella about a transverse axis. It’s deep surface, which looks directly posteriorly in extension:

a.) Faces superiorly when the patella, at the end of it down wards displacement in full flexion.

b.) Comes to lie against the femoral condyles. This movement can thus be called Circumferrential displacement.

The capsule forms three recesses in relation to the patella superiorly, the patella superiorly, the supra-patellar bursa.

PATELLECTOMY

On either side the para-patellar bursa recesses. When the patella slides under the condyles from A to B there.

Three recesses become unpleated and the distance become four times greater only because of the length of the supra-patellar bursa.

When inflammatory adhesions develop in these recesses their cavities are obliterated and the patella is tightly help against the femur and connot slide down the central groove.

This is one of the causes of the post-traumatic or post-infective stiff knee.

During downward displacement the infra-patellar pad follows the patella.

Normally the patella moves only in the vertical plane and not transversely.

It is a fact very strongly applied to its groove by the quadriceps, the more so as the degree of flexion increases.

a.) At the end of extension.

b.) Oppositional force is diminished and in hyperextension.

c.) It even tends to be reversed to separate the patella from the femur.

d.) The patella tends to be driven laterally because the quadriceps tendon and the ligamentum patella form an angle obtuse laterally.

The lateral lip of the patellar surface of femur prevents lateral dislocation of the patella.

PATELLO TIBIAL MOVEMENTS:

The patella infact exhibits two types of movements relative to the tibia, one type during flexion and extension, the other during axial rotation.

PATELLECTOMY

During flexion and extension the patella moves in saggital plane, starting from its position in extension.

It recedes while moving along the arc of a circle with center at the tibial tuberosity and radius equal to the length of the ligamentum patellae.

During the movement it is tilted on it self by an angle of about 35o

in such a way that deep surface, which faced posteriorly initially, looks posteriorly and inferiorly in full flexion.

Therefore it also undergoes a movement of cirumferential displacement, relative to the tibia.

During movements of axial movements of axial rotation, the patella moves relative to the tibia in frontal plane.

The displacements of the patella in relation to the tibia are therefore indispensable for movement of flexion and extension and of axial rotation.

During knee flexion, the femoral condyles move on the tibial condyles and the deep surface of the patella, dragged along by its ligamentous attachments, moves along a surface which is geometrically equivalent to the anterior profile of the femoral condyles, is the curve that encompasses the successive positions of the deep surface of the patellae.

The anterior profile of the femoral condyles is determined therefore essentially by the mechanical attachments of the patella and their arrangement just as the posterior profile of these condyles depends upon the cruciate ligaments.

PATELLECTOMY

INDICATIONS OF PATELLECTOMY

1.) Severe comminuted patellar fractures.

2.) Chondromalacia patellae.

3.) Severe patella femoral osteoarthritis.

4.) More damage to the articular cartilage of the patellae.

5.) Failure of internal fixation.

PATELLECTOMY

PATHOMECHANICS

Traumatic fractures of the patella occur with both direct and indirect mechanisms.

A direct mechanism, such as a fall, focuses the forces directly on the patella and results in a higher degree of cominution, less displacement of fracture fragments, and more damage to the angular cartilage, compared with the indirect mechanism.

Indirect mechanism, such as jumping increase tension and compression on the patella and result in less communition, increased fracture fragment displacement and less damage to the articualr cartilage.

Transverse fractures of the patella occur with indirect mechanism and they can be displace or non-displaced transverse fractures and to occur in the central aspect of the patella or in its distal third communition also be present.

Vertical fractures are rare, and they course superiorly to inferiorly in the saggital place.

Marginal fractures involve the edge of the patella and do not extend across the bone.

Osteochondral fractures occur as a result of direct or indirect blow and patellar dislocations, a separate type of osteochandral features occurs in children and adolescents called as sleeve fracture.

PATELLECTOMY

A sleeve fracture may involve the superior, inferior, medial, lateral aspects of patella.

When it involves the inferior pole usually with indirect trauma a portion of the patellar bone, the retinaculum and a large portion of articular cartilage is displayed inferiorly so that the larger superior feagment is high compared with the contralateral side.

Groganetal classified other types of avulsion fractures of patella these types include avulsion fractures of patella.

These types include avulsions of superior pole medial aspect and lateral aspect due to chronic stress at the site of insertion of the vastus lateralis muscle.

Patellar fractures may be secondary to anterior cruciate ligament reconstruction with an autogenous patellar tendon.

Pathological fracture of the patella has been reported in broad categories of diseases affecting the patella includes

Infection,

Degenerative

Metabolic diseases

Benign and malignant tumor types

are including chondroblastma.

Histocytosis giant cell tumor hemangioma,

Osteochondroma,

Lipoma brown tumor of hyper para thyroidism

And osteoblastoma.

PATELLECTOMY

CLINICAL FEATURES

Severe pain in and around the patella.

Tenderness due to the removal patella and immobilization.

Pain when moving the knee in both directions.

Swelling due to any inflammatory changes post surgically.

Possible inability to completely extend the leg or perform straight leg raising.

Increased local temperature due to infection.

PATELLECTOMY

DIAGNOSIS

1.) X-ray:

Views: antero-posterior view

Lateral view

X-ray findings confirm the absence of patella both in antero- posterior and lateral views.

Only tibiofemoral joint can be seen.

2.) CT scan:

It confirms the removal of the bony fragments of the patella.

Above the quadriceps tendon and the other soft tissues around the patella are preserved.

3.) MRI:

It is an appropriate and widely used invasive technique that confirms the soft tissue interpretation.

PATELLECTOMY

SURGICAL PROCEDURE

If there is significant comminuted fracture that cannot be adequately repaired, total patellectomy is performed.

In a full patellectomy complete removal of kneecap is done.

Incision

A linear incision is made over the front of the patella to expose the fracture kneecap the fracture pieces are examined and it is removed totally.

Only the bony fragments of the kneecap are removed the quadriceps tendon above the kneecap the patellar tendon or ligamentum patella below and the other soft tissues around the kneecap are preserved.

This surgery lasts approximately for 2hrs with administration of general anesthesia.

Following patellectomy incisions are closed with sutures or clips.

The extremity is immobilized in full extension in bandage or POP.

This allows tendon to tendon healing in an immobilization period of approximately 4weeks.

PATELLECTOMY

COMPLICATIONS OF PATELLECTOMY

1. Suture pull out: If partial patellectomy with suture of patellar ligament to patella may fail if the sutures pull out.

2. Anterior knee pain.

3. Quadriceps atrophy.

4. Development of osteo arthritis.

5. Ligament instability.

6. Pulmonary embolism.

7. Deep vein thrombosis.

8. Swelling.

9. Stiffness.

10. Knee buckling.

11. Difficulty in climbing stairs.

12. Inability to squat in the toilet.

13. Difficulty in kneeling or sitting cross legged on the floor.

14. Difficulty in getting up from prolonged sitting posture due to pain.

PATELLECTOMY

POST OPERATIVE MANAGEMENT

AIMS:

1.) To reduce the pain over the surgery area.

2.) To reduce the edema.

3.) To take care of the cast or knee immobilizer.

4.) To maintain the mobility of the unaffected or normal joints.

5.) To avoid surgical complications.

6.) To teach the weight bearing.

MEANS:

1.) Adequate pain medications will be given either orally, intravenously or intramuscularly to reduce the pain

2.) Elevate the injured leg above the heart level to help blood drain towards the body and also helps for to relieve the edema.

3.) Proper care must be taken for the cast or knee immobilizer should be kept clean dry and intact. Wrap it in a plastic shower bag when the patient comes in contact with the water.

4.) In order to improve the circulation and preserve the joint ROM patient is asked to move hip joint flexion/extension and abduction/adduction at ankle joint plantar/dorsiflexion with the assistance of therapist.

5.) Necessary steps should be taken to avoid surgical complications.

6.) The crutches/frames are advised to bear some weight.

PHYSIOTHERAPY ASSESSMENT

PATELLECTOMY

SUBJECTIVE:

1.) Name

2.) Age

3.) Sex

4.) Occupation

5.) Address

Presenting chief complaints:

Mechanism of injury.

About pain.

Side.

About duration.

Onset.

Progression of symptoms, severity, and associated symptoms must be recorded.

Problems regarding the activities.

Past history:

Any similar problem in the past.

Diabetes.

Hypertension.

Rheumatism.

Asthma.

Allergy.

Tuberculosis.

PATELLECTOMY

Chest and heart problems.

Enquire about all the treatments the patient has that include,

Medicines like NSAIDS, steroids etc..

Intra articular steroid injections etc..

Ask for any allergy for medicine.

Physiotherapy treatment.

Plasters orthosis.

Family history:

Enquiring about the general family health.

Occurrence of any familial or hereditary diseases.

Support from the family in terms of psychological and financial aspects.

Personal history:

Smoking, alcohol consumption, diet etc..

Social and occupational history:

Type of place of living.

Presence of stairs at home and toilet facilities Indian/western type.

Hobbies and patients leisure activities must be noted.

Exact nature of occupation heavy manual work/sedentary.

ON EXAMINATION

1.) Examination of pain:-

PATELLECTOMY

Pain, which is felt by the patient, is an important symptom that gives clue to the diagnosis.

a. Site of pain:

Localized or diffused.

Ask the patient to denote the maximum point of pain and extent of pain.

b. Severity of pain:

Mild/moderate/severe.

c. Nature of pain:

Aching/stabbing/burning/throbbing/constricting/

Gripping/prickling pain.

d. Progression of pain:

Worse/same/decreased in time constant/on and off.

e. Aggravating and relieving factors:

Aggravating during joint movements.

1. Walking.

2. Standing.

3. Body posture exercises.

Relieved by any analgesics fomentation and other means.

Pain intensity involves having the patient rate the current level of discomfort in one of the following ways.

PATELLECTOMY

1.) Verbal rating scale:

No pain |--------------------------------------| severe pain

Mild / moderate

Pain is subdivided into gradually increasing pain intensities using words.

2.) Visual analogue scale:

No pain |---------------------------------| maximum

The patient rates the pain on a scale that has no subdivision.

3.) Pain estimate scale:

0 |------------------------------------------| 100

The patient rates the scale of 0-100 where 0-represent a lack of pain and 100 represents most severe pain felt.

ON OBSERVATION:

a.) Body type.

i.) Ectomorphic.

PATELLECTOMY

ii.) Mesomorphic.

iii.) Endomorphic.

b.) Posture:

- Any abnormal deviations are noted like forward or lateral bending of trunk. (Scoliosis, kyphosis).

c.) Deformities:

- Any abnormal deformities are noted like genu varum and genu recurvatum.

d.) Abnormal movements:

- Abnormal movements are noted like pelvic tilt.

e.) Attitude of limb:

- Check for position of the limb

ON PALPATION:

a.) Checking for vital signs like

Temperature.

Blood pressure.

Heart rate.

Respiratory rate.

Pulse.

b.) Tenderness:

Palpate the tender spot and assess the soft tissue and bony tenderness individually.

c.) Warmth: This is felt using the dorsum of the hand and compared to the other side inflammatory conditions and infections produce increased warmth.

d.) Gaps: Feel for any defect in the quadriceps mechanism due to rupture.

PATELLECTOMY

e.) Distal pulsation: Check for dorsalispedis and posterior tibial artery pulsation.

f.) Swelling:

1.) First notice – When did the patient notice.

- During what activity patient noticed.

2.) Symptoms associates with lump:

- Pain.

- Pressure symptoms affecting movement of adjacent joints.

3.) Progression of lump:

- Getting bigger/smaller.

- Disappear and re-appearing in positions and different times.

4.) shape:

- Hemispherical, horse shoe shaped.

Measurement for swelling:

Measure the swelling around the knee joint with an inch tape.

MOTOR EXAMINATION:

Strength/power is by oxford grading scale from 0-5

0-Nocontraction.

1- Flicker of contraction.

2- Full ROM with elimination of gravity.

PATELLECTOMY

3- Full ROM with against gravity.

4- Full ROM with against gravity minimal resistance.

5- Full ROM with against gravity Maximal resistance.

Muscle wasting: Wasting is assessed by inch tape measurement compared to the normal limb commonly seen in hamstrings and quadriceps.

Muscle tone: To identify tone of the muscle in the case of patellectomy.

Range of motion: Decreased range of motion of knee joint decreased flexion due to shortening of quadriceps.

Limb length: Normally shortening of the affected limb.

SENSORY EXAMINATION

Superficial: Touch- Fine/crude.

Pain- Superficial/deep.

Temperature- Hot/cold.

Deep: Joint position.

Vibration.

POSTURE:

To check the Scoliosis spondylometer is used.

Plumb line test:

Rope is used with weight fixed at end of rope and checks the posture.

Any deviation from normal line noted as postural deviation.

PATELLECTOMY

Posture is alter due to muscle contracture and pain.

GAIT:

1.) Antalgic gait/Painful gait.

2.) Arthrogenic gait.

1.) Antalgic gait:

In patellectomy after removing of the cast the pain is present so the patient having painful or Antalgic gait.

In this the stance phase on the affected leg is shorter than that on the unaffected leg, because the patient attempts to remove weight from affected leg as quickly as possible.

Therefore the time on each leg noted. The stance phase of the involved leg is decreased.

The result is shorter step length on the involved side, decreased walking velocity, and decreased cadence

2.) Arthogenic gait:

Due to contracture of quadriceps muscles in the patellectomy, the Arthrogenic gait is present.

The patient with this gait lifts the entire leg higher than normal to clear the ground because of a stiff knee.

PATELLECTOMY

Because loss of flexibility in the knee, the gait lengths are different for the two legs. When the stiff limb is bearing wait, the gait length is usually smaller.

FUNCTIONAL ASSESSMENT:

To know the ability of perform normal activities of daily living, that is in

Standing Sitting Lying Walking Other daily activities like use of toilets and dressing.

SPECIAL TESTS

1.) STRAIGHT LEG RAISING:

Active extension is assessed by this test. Lack of terminal extension can be due to fixed flexion deformity or extension lag.

The quadriceps lag is assessed by the ability to passively extend fully.

The passive extension is assessed by lifting both heals to know fixed flexion with one hand on the knee is used to assess for crepitus or any loose body movements.

2.) Q- ANGLE:

Knee is 20o flexion, legs crossed over a pillow on imaginary line is drawn from anterior superior iliac spine to center of patella and from these to tibial tuberosity.

PATELLECTOMY

Angle formed by these two lines is the q- angle.

Normal range- 8-10 o in males and 12-15 o in females.

Feel for the size of patella, tenderness in the parapatellar and retropatellar surface, evidence of patella Alta or Baja by measuring the height patella and the length of patellar tendon in 30 o flexion of knee normally these are of same length.

PHYSIOTHERAPY TREATMENT

During immobilization period:

The immobilization period is 4-6 weeks with a plaster cast/ pop.

During this time:

PATELLECTOMY

Strengthening the crutch muscles like:

* Shoulder adductors and extensors

* Elbow flexors and extensor

* Wrist and finger flexors

Weight bearing:

* The patient is allowed full weight bearing in cast or knee mobilizer.

* The immobilizer can be removed for performing active range of motion exercises to the knee in a sitting position.

* Weight bearing is not allowed while performing active ROM exercises because there may be uncontrolled flexion of the knee and disrupting the fixation devices.

ROM

* In patelectomy only active range of motion exercises are allowed.

* The active ROM exercises begun at the hip and ankle level in all planes.

* Initially the hip may be sore after fall. Hip flexion may be painful secondary to activation of the rectus femoris because it also flexes the hip

* Straight leg raising is initiated as tolerated.

PATELLECTOMY

Muscle strength:

* Isotonic exercises are prescribed to the dorsiflexors and plantar flexors of the ankle to prevent ankle stiffness and reduce the risk of thrombo-phlebitis.

* Sets of gluteal exercises are to maintaining strength of the glutei

* Group which help to extend the hip and allowed the patient to raise up from to chair.

Gait:

* Because the affected knee is kept in extension the patient may have to circumduction the extremity or hip hike to clear the floor.

* Initially crutches or a walker may be used for support.

During mobilization period:

Once the cast has been removed or use of a knee immobilizer has been discontinued after 4-6 weeks physiotherapy is started.

AIMS of physiotherapy treatment:

1. To reduce pain.

2. To provide effective extensor mechanism.

PATELLECTOMY

3. To prevent deformities and contractures.

4. To increase joint ROM.

5. To improve muscle power/strength.

6. Posture correction.

7. To improve gait pattern.

8. To maintain functional independence.

MEANS:

1. To reduce pain.

Adequate heat modalities are given to relieve the pain.

Therapeutic heat increases local and regional circulation, reduces tissue viscosity, and improves collagen elasticity.

Therapeutic heat also reduces the firing rate of both muscle spindle and peripheral pain receptors (nociceptors).

PATELLECTOMY

Heating may be applied directly using hot packs(thermal energy) or by converting ultrasound(acoustic energy) microwaves.

For superficial heat

a.) Hot packs.

b.) Paraffin wax.

c.) Fluid therapy.

2. To provide effective extensor mechanism

By electrical re-education to quadriceps provide effective extension.

Procedure: Placing towel under foot, slow sustained push with hands downward on quadriceps.

3. To prevent deformities and contractures:

Wearing an orthotic appliance the mild degree of genu varum deformity is corrected prevents deformities.

PATELLECTOMY

The orthotic appliance consisting of boots with a ling inner rod extending to the groin and leather straps crosses the tibia and the knee. (KAFO)

Stretching the hamstrings relieves the contractures.

Deep heat gives more effective to relieve contractures by ultra sound and short wave diathermy.

4. To increase joint ROM.

Gentle active assisted exercises and passive ROM exercises are performed to improve the jointROM.

Initially the knee may lack full flexion because of the immobilization.

The patient may also have an extension lag secondary to weak quadriceps that is gained by active assisted exercises.

Terminal knee extension:

Place a bolster, such as a rolled-up towel, beneath the lower part of patient thigh, about two to three inches above the knee. Straighten the knee to extend the leg. The goal is to straighten the leg into the air, using the towel as a fulcrum.

Straight leg raising:

Bending one knee and place foot flat on bed. Keeping the other knee straight, lift the straight leg up about 12-20inches. Count to five slowly while lowering leg.

Assisted knee extension:

PATELLECTOMY

Lying on a flat surface by keeping affected leg straight and bends the unaffected limb. Place a small bolster, such as a rolled-up towel, under the ankle of the straight leg. Push down from the bottom of the thigh of the straight leg. Extend the knee just as much as it takes to straighten the leg.

Prone resisted knee flexion:

Lying face down on a flat, firm surface with legs straight. Flex knees to raise legs. Place the non-injured leg over the injured leg. Push down with the non-injured leg while the injured knee pushed up. Against resistance, bring legs back to floor. Do three sets of 10.

Prone assisted knee flexion:

Lying face down on a flat, firm surface with legs straight. Place the injured leg over the non-injured leg. Push up with the bottom non-injured leg, with the top leg passive. Do three sets of 10.

Sitting knee extension:

Sit on the edge of a solid table or bed and extent the knee so patient leg is in straight and not to be hyper extended. So do three sets of ten. Repeat with other leg. As the patient get stronger, can add a 3-5 pound ankle weight. If the patient is recovering from a total knee replacement, do not add ankle weight.

Hamstring curl:

Ask the patient to stand on his thighs against a surface, bend one knee as far as it can go for 10sec. Lower the foot slowly, repeat it 10times.

Rowing machine

PATELLECTOMY

To improve the power/strength.

For strengthen the quadriceps muscles or knee extensors

When the patient is able to bear weight on effected leg, the therapist allows him to strengthening program.

STRENGTHENING

Extensors: quadriceps are rectus femoris, vastus medialis, vastus medialis, vastus lateralis.

Assisted exercises: manual springs suspension

Free exercises:

A. Non-weight bearing:

1] Lying; static quadriceps contraction [setting]

2] Lying/standing; one hand resisting plantar

flexion and quadriceps.

3] Prone lying; [feet dorsiflexion] knee extension.

B. Lying; quadriceps contraction followed by SLR.

C. Side lying; hip knee bending and stretching

D. Crook lying; knee flexion-extension

WEIGHT BEARING EXERCISES

A] Back against standing.

B] Standing; step up and down

PATELLECTOMY

C] Toe standing.

RESISTED EXERCISES

Manual-sitting

Pulley- sitting

Dead weights board-using static and dynamic

Quadriceps

Squatting with bars

PROGRESSIVE RESISTED EXERCISES:

Non- weight bearing:

Activities:

Bicycling

Breast Stroking

Swimming

Walking, with knee standing.

Weight bearing:

Walking down hill stairs

Skipping

Lifting heavy objectives ties to knees.

FLEXORS: Hamstrings :

Biceps femoris

Semi membranous

Semitendinosus

Adductor part of Magnus

Assisted exercises:

PATELLECTOMY

Manual

Suspension

Re-education

Free exercises:

Side lying-one hip and knee bending

Standing-one hip and knee bending

Prone lying –assisted flexion and extension of one knee

Crouch position, crouch bunny, jump.

Resisted exercises:

Side lying, manual resistance.

Springs

Dead weight to leg : standing

Pulley

Activities :

walking

running

jumping

Squatting.

For Dorsi-flexors:

Free exercises:

Full ROM is made possible by bending the knee.

Inclined long sitting – leg flexion and ankle dorsiflexion.

Long sitting – ankle dorsi flexion, alternatively.

Prone kneeling –one foot dorsiflexion with or with out leg movement.

PATELLECTOMY

Resisted exercises:

The resisted applied on the dorsum of the big toe, of extensors digitorum longus by resistance on the dorsum of the toes.

Tibialis anterior contracts most strongly when dorsiflexion and inversion are resisted.

Resistance applied by using the weights, pulley aid weight, and springs.

FOR ANKLE JOINT:

Plantar flexors: Gastrocnemius, soleus.

Free exercises: long siting / half standing: toe pointing, alternatively

Prone lying of feet over end of plinths, toe pointing, alternatively

Sitting one heel raising.

Resisted exercises:

Long sitting (with knees bent)

Resistance is given on a sufficient area of the sole to avoid straining the intertarsal joints and plantar structures.

Fixing the ankle the ankle joint in dorsiflexion and resisting under the toes can localize the action of the long flexors.

Weight bearing:

Reach grasp high standing

Half standing: one heel raising

POSTURAL CORRECTION:

Asking the patient stand infront of the mirror for postural Re-education.

PATELLECTOMY

Postural correction is obtained by giving a heel and sole rise to effected limb when there is a limb length discrepancy.

In case of moderate scoliosis activity correction by Milwaukee spinal braces or modified plastic braces are prescribed.

TO IMPROVE GAIT PATTERN

By reducing the pain and stiffness of the knee by appropriate therapeutic methods the gait will be normal.

General and physiotherapy management along with patient education regarding the daily activities like standing, sitting, squatting and usage of orthotics.

HOME ADVISES

The patient is instructed in rolling over to one side and coming to sitting position.

The patient is also advised from a lying position by pushing up using the upper extremities.

The patient is asked to sleep on the side of concavity to correct the lateral bending of the trunk [Scoliosis].

As full weight bearing is allowed the patient performs ambulatory transfers using the effected extremity.

Initially assistive devices such as crutches or a walker frame may be used for support during transfers because the patient may have soreness and pain.

PATELLECTOMY

The activity time should be built up gradually with frequent rest periods between activity periods.

The patient is instructed to don pants with the affected extremity first doff them from the unaffected extremity first. This is the easiest way to dress up.

An elevated toilet seat is helpful for personal hygiene.

CASE STUDY-1

Name : Varma

Age : 30yrs

Sex : Male

Occupation : Painter.

Address : Ramvarappadu, Vijayawada.

Chief complaints :

Pain at knee joint.

Side – left.

Decreased bending(flexion) at knee joint.

Duration - 3 months.

Automatically trunk is bending towards affected side.

History of injury:

Date of injury- 3 months back.

Type of surgery -total patellectomy.

PATELLECTOMY

History of fracture:

1. Patient falls from height (ladder) over the patella, when painting the roof.

2. Resulted in comminuted fracture of patella confirmed by X-ray study.

3. Fracture is corrected by surgical exertion of patella.

4. No history of diabetes, hypertension and previous surgeries.

Family history:

- Poor family background.

- Good relations with the family members.

Personal history:

- Known smoker.

- Marital status- married.

ON EXAMINATION

Pain examination :

Side-left knee joint.

Type – continuous.

Aggravating factor- on movements.

Relieving factors- Rest and NSAIDS.

Progression of pain- gradually increases.

On observation:

- Built of the patient- thin built.

- Swelling- moderate edema is present

- Deformity- mild genu-varum is noted.

PATELLECTOMY

- External appliance- patient came with figure of ‘8’ bandage.

- Posture- left Scoliosis is noted.

- Gait- painful gait is noted.On palpation:

- Vital signs are noted- normal.- Tenderness is – positive.- Distal pulsation-increased pulse.- Swelling-medial or lateral side of the knee

joint.

On examination:

ROM

Knee flexion- 0-60 o.

Knee extension- 60-10 o.

Extensor lag – 10o

Examination of muscle power:

Quadriceps – 2

Hamstrings – 3

Muscle wasting:

Is measured with inch tape and it is more compared with normal limb.

Affected limb:

Quadriceps – 20 cm

Calf muscles – 15 cm

Normal limb:

Quadriceps – 30 cm

Calf muscles – 20 cm

Measurements:

Limb length:

PATELLECTOMY

Is measured by an inch tape limb shortening is present compared with normal limb.

Affected limb – 88cm.

Unaffected limb – 90cm.

Findings: X-ray union (tendon-tendon).

Physiotherapy Treatment

Aims

1. To reduce pain.

2. To provide extensor mechanism.

3. To prevent deformity

4. To improve muscle power / strength.

MEANS:

To reduce the pain.

Adequate heat modalities are given.

For superficial heat: a) Hot packs

b) Paraffin wax

c) Fluid therapy

To provide the extensor mechanism

Electrical reeducation to quadriceps by faradic current.

To correct the posture

To prevent deformity (trunk side bending) scoliosis, by Milwaukee spinal braces or modified plastic braces are prescribed.

PATELLECTOMY

Asking the patient stand in front of the mirror for postural reeducation.

To improve muscle power / strength

Strengthening extensors and flexors of the knee joint like weight- bearing exercises, resisted exercises, progressive resisted exercises are prescribed like bi cycling, swimming, and walking.

Home advises

1. The patient advised from lying position by pushing up using the upper extremities.

2. As full weight bearing is allowed, the patient performs ambulatory transfers using the affected extremity.

3. The activity time should be built up gradually with frequent rest periods.

PATELLECTOMY

CASE STUDY-2

Name : Venkata Rao

Age : 38 yr.

Sex : Male.

Occupation : Electrician.

Address : Labbipet, Vijayawada.

Chief complaints :

a.) Severe pain at the knee joint.

b.) Patient is unable to bend the knee joint.

c.) Duration: 45 days.

d.) Side: left.

e.) Stiffness at the knee joint.

f.) Walking pattern alters (due to pain).

History of injury :

Date of injury: 45 days.

Type of surgery: Total patellectomy.

History of fracture:

- Patient falls from current pole while climbing on it.

PATELLECTOMY

- Resulted in comminuted fracture of patella confirmed by X-ray study.

- Fracture is corrected by surgical extension of patella.

- No history of diabetes, hypertension and previous surgery.

A direct fall from height over knee joint, which results in comminuted fracture of patella.

Past history :

Family history :



Personal history :

- Married.

- Known smoker.

On examination

Pain examination :

Site : at knee joint.

Type : pain occurs continuously.

Aggravating factors : Pain aggravates when patient moves

his legs.

Relieving factors : Rest and NSAID’s.

Progression of pain : gradually increases.

ON OBSERVATION

- Built of the patient- thin built.

- Swelling moderate swelling positive.

- Deformity: mild genu varum is noted.

PATELLECTOMY

- External appliance: patient came with figure of crepe bandage.

- Posture: right Scoliosis noted.

- Gait: painful gait.

On palpation:

Vital sings are noted as normal.

Tenderness: it is positive.

Distal pulsation: increased pulsation.

Swelling: the patient noticed during movement of knee joint.

On examination:

ROM

Knee flexion- 0-50o.

Knee extension- 50-10 o.


Quadriceps – +2

Hamstrings – +3

Muscle wasting: more compares with normal limb.

Affected limb:

Quadriceps: 20 cm

Calf muscle : 15cm

Normal limb:

Quadriceps: 30 cm

Calf muscles: 20 cm

Measurements:

PATELLECTOMY

Limb length measurement

By inch tape limb shortening is present compared with normal limb.

Affected : 85 cm. Normal : 87 cm.

Findings: X-ray union (tendon-tendon).

PHYSIOTHERAPY TREATMENT:

AIMS:

To reduce pain

To prevent contractures

To improve gait pattern

Postural correction.

Means

To reduce pain by giving therapeutic modalities like infra red lamp paraffin wax, fluid therapy, heat pads.

To prevent contractures stretching to hamstrings, ultra sound to relieve contractures.

To improve gait pattern due to pain anatalgic gait is present. So appropriate therapeutic methods are used to relieve pain so that can improve the gait pattern.

Postural correction – by giving Milwaukee brace postural reeducation in front of the mirror.

Home advises - the patient is instructed to done pants with the affected extremity first doff them from the unaffected extremity first. This is the easiest way to dress up.

An elevated toilet seat is helpful for personal hygiene. The patient is asked to sleep on the side of concavity to correct the lateral bending of the trunk (scoliosis).

PATELLECTOMY

CASE STUDY-3

Name : Devaraju.

Age : 26 years.

Sex : Male.

Occupation : Lorry cleaner.

Address : satyanarayanapuram, Vijayawada.

Chief complaints :

- Pain around knee joint.

- Duration- 2 months.

- Side- (Right).

- Deviation of the joint at knee (genuvarum)

- Unable to do daily living activities like squatting at toilet.

History of injury :

- A direct blow on patella resulted in comminuted fracture.

Type of surgery : Total patellectomy

History of fracture :

- Date of injury- 2 months back.

- Type of surgery-total patellectomy.

PATELLECTOMY

- Patient met with a road traffic accident, direct blow over the right knee joint anteriorly.

- Resulted in comminuted fracture of patellae confirmed by X-ray study.

- Fracture is corrected by surgical Excision of patella.

- No history of diabetes, hypertension and previous surgeries.

Family history:



Personal history:

- Known smoker.

- Used to take alcohol.

Marital status: Unmarried.

On examination:

Pain examination

- Site- right knee joint.

- Type- continues.

- Aggravating factors- on movements.

- Relieving factors- Rest and NSAID’s.

- Progression of pain-Gradual increase.

ON OBSERVATION

- Built of the patient- Mesomorphic or medium.

- Swelling: mild, pitting edema is noted around the right knee.

PATELLECTOMY

- Deformity: mild genu varum deformity is noted.

- External appliance: patient came with KAFO

- Posture: left Scoliosis is noted.

- Gait: antalgic gait is noted.

On palpation:

- Vital signs are noted – normal.

- Tenderness is positive.

- Distal pulsation- increased pulse.

- Swelling- the patient is noticed during movement of the knee joint.

ON EXAMINATION

Examination of ROM

- Knee flexion-0 – 60o.

- Knee extension-60-10o.

- Extensor lag - 10o.


- Quadriceps-2+

- Hamstrings-2+

Muscle wasting:

- It is measured with inch tape, it is more in affected limb compared with normal limb

Affected limb:

- Quadriceps: 20 cms

- Calf:15 cms

Normal limb:

PATELLECTOMY

- Quadriceps: 30 cms

- Calf: 20 cms

Measurements:

- Limb length is measured by measured by inch tape, limb shortening is present compared with normal limb.

Affected limb: 88 cms

Normal limb: 80 cms

X-ray findings:

- X-ray union (tendon to tendon)

PHYSIOTHERAPY TREATMENT:

Aims:

- To reduce the pain,

- To increase the joint range of motion

- To correct the deformity

- To improve the functional activities

Means:

- To reduce the pain:

- Adequate heat modalities are given to relieve the pain

- For superficial heat:

- Hot packs

- Paraffin wax

- Fluid therapy

PATELLECTOMY

To increase the joint range of motion:

- Gentle active assisted exercises and passive ROM exercises are performed to increased joint ROM by:

- Terminal knee extension

- Straight leg raising

- Prone resisted/assisted knee flexion

- Hamstring curl

To correct the deformity:

- By wearing an orthotic appliance the mild degree of genu-varum deformity is corrected.

- The orthotic appliances consisting of boots with a hinge inner rod extending to the groin and leather straps crosses the tibia and knee (KAFO).

To improve functional activities:

- By using western type of toilets

- The patient is instructed to don the pants with the affected extremity first doff them from from the unaffected first.

- This is the easiest way to dress up.

PATELLECTOMY

Home advises:

- The patient is instructed in rolling over to one side and coming to sitting position.

- The patient is also advised from a lying position by pushing up using the upper extremities.

- The patient is asked to sleep on the side of concavity to correct the lateral bending of the curve that is scoliosis.

PATELLECTOMY

CONCLUSION

Existing physiotherapy management after patellectomy have been shaped by years in large numbers of patients.it has exalt and concluded that the periodical evolution and follow-up assessment, the case which has undergone patellectomy of various ages was given intense physiotherapy post-operatively as well as conservatively reduced complications after patellectomy.

The patellectomy rehabilitation specifically based on the post-operative assessment, which included in this cumulative work.

The objective is to materialize the functional independence. More significantly physiotherapy procedures which was carried out sets are not to leave the patient with any sort of disability.the ambulatory process was carefully observed, explained with demonstration, which has ultimately substantiate to be successful.

I conclude this project work with gratificantly, the patient is now functionally independent.

BIBLIOGRAPHY

PATELLECTOMY

1. HUMAN ANATOMY -B.D. CHAURASSIA.

2. JOINT STRUCTURE AND FUNCTION - CINTHIA NORKIN.

3. TEXTBOOK OF ORTHOPAEICS - JOHN EBNIZER.

4. ESSENTIALS OF ORTHOPAEDICS ND - JAYANT JOSHI APPLIED PHYSIOTERAPY PRAKASH KOTWAL

5. THE PRINCIPLES OF - M. DENA GARDINER. EXERCISE THERAPY

6. MERCER’S - ROBERT B. DUTHU. ORTHOPAEDIC SURGERY

7. ORTHOPAEDIC PHYSICAL - DAVID J. MAGEE ASSESMENT

8. CLINICAL ASSESSMENT AND - C. REX EXAMINATION IN ORTHOPAEDICS

9. ORTHOPAEDICS AND - M. NATARAJAN. TRAUMATOLOGY

10. MANUAL OF ORTHOPAEDICS - MARC F SWIONTKOWSKI

11. TREATMENT AND REHABILITATION - STANLEY Q OF FRATURE HOPPEN FELD

VASANTHA MURTHY

12. TEXT BOOK OF REHABILITATION - S. SUNDER

13. CLINICAL ORTHOPAEDIC - S. BRENT BROTZMAN. REHABILITATION

14. JOINT PHYSIOLOGY - KAPANDJI VOLUME-2

Pa Tell Ectomy

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