Exercises after distal femoral extension osteotomy and patella advancement surgery

This resource has been designed to help you remember the exercises and advice the therapist went through with you whilst in hospital.

The exercises should be done slowly and smoothly. Some discomfort may be noted whilst doing these exercises after surgery. If pain is limiting doing the exercises, then timing them around pain relief or muscle relaxant medication may be helpful. However, if pain becomes worse please seek advice from a healthcare professional and stop the exercises.

After surgery it is important for the bones and muscles to heal in their new position. In order for the surgery to be successful it is important to follow the daily program as instructed by your child’s therapist.

Exercises

Hip abduction

Start by lying your child on their back.

Make sure your child’s hips are level. Support their leg under the heel and knee.

Gently and slowly take one leg out to the side with the knee and toes pointing up and the knee straight. Continue to take the leg out to the side until resistance is felt then hold this position for 10 seconds. Keep their other leg anchored to stop any movement in it.

Return back to the starting position. Repeat 10 times on each leg.

Ankle exercises

Start by lying your child on their back or propped up.

Make sure your child’s knee is straight. With one hand grasp underneath the heel, place your forearm along the bottom of your child’s foot.

Slowly apply pressure on the foot with your forearm so that the toes point up and back towards the child’s body until resistance is felt. Hold this position for 10 seconds.

Return back to the starting position. Repeat 10 times on each leg if both operated on.

Knee bends

This exercise is to be started 2 weeks after the operation and the amount of knee bend allowed will gradually increase.

Start by lying your child on their back or in reclined sitting. Remove the brace for this exercise.

They should be aiming to achieve a minimum of 30 degrees by week 4, 60 degrees by week 6 and 90 degrees by week 8, the amount of bending achieved will be monitored by their physiotherapist.

Support your child’s leg under their heel and at their knee. Bend their knee by moving the heel towards the bottom and knee towards the chest.

Return to the starting position. Repeat 10 times per leg.

Static quads (knee squashes)

For children who are able to, trying to strengthen their thigh muscles can help with tightness in the hamstring muscles that bend the knee.

Start lying on your back.

Push your knee down firmly against the bed. Keep your leg straight with your knee and toes pointing upwards. Hold for 5 seconds.

Repeat 10 times.

Static glutes (bottom squeezes)

For children who are able to, keeping the muscles around the pelvis working whilst they are less active helps maintain strength whilst they are less active.

Squeeze your bottom muscles together. Hold for 5 seconds.

Repeat 10 times.

How many times should I do these exercises?

These exercises should be done a minimum of 3 to 4 times a day and they should be staggered throughout the day. Any positive positions your child’s therapist has advised should be adopted whenever they are resting

What else can improve the outcome of my surgery?

Positioning and braces

Positioning is an effective way of maintaining muscle length and allowing the bones to heal in their new position. Holding a positive position for a prolonged period of time will help with this.

For the first 2 weeks your child’s knees must be straight at all times. At 2 weeks they can start gradually increasing how much they can bend their knees with the above exercises. How much bending they achieve will depend on how it feels, it will feel strange and uncomfortable but it should not be too painful. The aim is to achieve 90 degrees of knee bend by 8 weeks after the operation. Their physiotherapist will measure and monitor how much knee bend you have.

The aim of surgery is to get the knees straight and therefore for the first 8 weeks whenever not doing exercises they should be wearing the braces or gaiters as advised by the hospital therapy team to hold their knees straight. You should check the braces every day that the settings are as they should be. Always keep their heels off the bed or other surface to prevent any pressure issues.

Sleeping and sitting

If your child has a sleep system their local therapist should adapt it to accommodate their new position. They should sleep in their braces on the settings advised by the therapists.

We will have arranged for leg rests on their wheelchair to support their legs out straight. They should gradually build up their time sitting in their wheelchair before leaving hospital and continue to build this up at home,

Walking, standing and hydrotherapy

No weight must be put through the legs for 6 to 8 weeks or until they have been back to clinic and had an X-ray. After this time they may begin to stand and bear weight but are encouraged to gradually build up their activity and be guided by your physiotherapist. Initially all weightbearing must be in the braces to keep the knees straight.

Hydrotherapy is encouraged to work on movement once the wounds are healed.

Returning to school

Your child will require a period of time off school or college, how long this will be is dependent on each individual situation. To return to school or college your child needs to be comfortable on the medication they can take at school/college. They need to be able to sit for the necessary length of time for travelling and the school day, as well as safely transfer for the toilet with the amount of support school or college can provide. It is helpful to speak to your therapists and school or college before surgery to find out what the options will be and then monitor progress after the operation.

Managing pain and pressure

Increased pain or discomfort is expected after this operation. Having appropriate pain and muscle relaxant medication can help manage this.

It is important to make sure there is no pressure damage by regularly checking the skin for redness or evidence of rubbing. Any red marks should disappear after 30 minutes of the braces being removed. If marks do not disappear and pain continues discuss this with your child’s therapist.

Increased tolerance and time wearing the braces will increase the effectiveness of the surgery but issues around pain and skin integrity must be addressed.

What happens next?

We will contact your child’s local therapist to pass on any important information and ask them to see you at home or in school. Your therapist will review your child’s muscles length, exercises and positioning.

It is important that you see your therapist once you leave the hospital so they can continue to help with your child’s exercises and rehabilitation. Your therapist can guide your child’s rehabilitation however it is your responsibility to make sure your child completes the necessary exercises.