Introduction
Appropriate post-operative management following fracture and joint surgery is critical for success and can be as important in determining the outcome of the case as the surgery itself. In general, post-operative management should be directed at allowing early pain-free controlled mobilization of the limb in order to prevent “fracture disease” (i.e., joint stiffness, osteoporosis, muscle atrophy or contraction) as well as the prevention of complications such as infection, soft tissue injuries and bone destabilization.
This lecture is intended to be a practical outline of my post-operative management strategies. I am not a veterinary physiotherapist and therefore do not have access to elaborate physical therapy equipment or techniques but hope to present a basic approach that would be applicable to all general practitioners.
Post-operative Antibiotics
The prophylactic administration of peri-operative antibiotics for orthopaedic procedures should be reserved for procedures expected to last more than 90 minutes in duration, open contaminated fractures, or where there is anticipated blood pooling and haematoma formation. The implanting of orthopaedic implants is not in itself an indication for prophylactic antibiotic treatment unless the patient is immunocompromised, where there is sparse soft tissue coverage of the implants, or if an infection would be disastrous to the surgical procedure (e.g., total hip replacement). Peri-operative antibiotics are given intravenously at induction. With very long or high-risk procedures, additional doses are given at frequencies depending on the drug’s MIC and half-life for up to 24 hours post-operatively. Antibiotic treatment for longer than 24 hours post-operatively has not been shown to reduce infection rates and may perpetuate bacterial resistance.
Physiotherapy in the form of “cold therapy” can begin the day after surgery to help reduce swelling and pain. The old bag of frozen peas has been replaced by a variety of more modern gel-like products that retain cold (or heat). Cold therapy should be applied for 10 to 15 minutes bid or tid. When treating marked oedema, cold therapy can be applied on alternate 30 minute intervals on the day of injury. On the following day, it may be more effective to alternate cold with heat therapy to cause constriction and dilation of vessels to aid venous and lymphatic return.
“Heat therapy” begins from 48 hours after surgery or on the day of RJB removal. Owners are instructed to apply heat therapy to the area for 10 to 15 minutes twice daily. A “wheatie bag”, which has been warmed (together with a glass of water) in a microwave oven, is an excellent way of applying heat. Alternatively, gamgee bandages or cotton wool can be immersed in hot water and wrung out and carefully applied. Hand massage of the distal limb is performed at this time to improve circulation flow and reduce oedema. Some owners like to use herbal rubs such as Aloe Vera or Arnica and these can be massaged over areas of bruising and swelling at this time. I encourage heat treatment and massage for 2 to 3 days or longer if required.
Passive range-of-motion (PROM) exercises can begin from day 1 post-operatively or on the day of bandage removal. Ideally, all joints of the affected limb should receive PROM exercises 2 to 3 times a day. During each session, a minimum of 10 flexions and extensions should be performed on each joint. After flexion and extension of the individual joints, the entire limb should be cycled through its full, pain-free range-of-motion 10 times. Stifle movement should be slow and gentle initially. The owner should be instructed never to force the joint or cause pain, but gently maneuver the limb through a range-of-motion that is well tolerated. PROM exercises are encouraged for the first 4 weeks after surgery.