Rehabilitation Protocol Following Proximal Tibia Fracture Fixation Surgery

Proximal tibia fractures, including tibial plateau fractures, are complex intra-articular injuries that involve the weight-bearing surface of the knee joint. These fractures account for approximately 1% of all adult fractures and constitute a significant challenge due to their complex anatomy and the biomechanical forces acting upon the knee. Epidemiologically, these fractures occur predominantly in two populations: younger males following high-energy trauma (e.g., road traffic accidents, sports injuries) and older females with osteoporotic bone who sustain low-energy injuries such as falls.

Treatment options range from conservative management for non-displaced fractures to surgical intervention involving open reduction and internal fixation (ORIF) with plates, screws, or less invasive stabilization systems (LISS). Surgical goals focus on anatomic reduction of the articular surface, restoration of mechanical alignment, and stable fixation to allow early mobilization.

• Goals:
  • Protect surgical fixation and promote fracture healing.
  • Control pain and inflammation.
  • Prevent joint stiffness and muscle atrophy.
  • Maintain cardiovascular fitness as tolerated.
• Interventions:
  • Knee immobilization with brace in extension during ambulation
  • ROM allowed: typically 0-90° flexion restriction depending on fracture/ligament injury).
  • Cryotherapy and limb elevation (15-20 cm) to reduce swelling and pain.
  • Neuromuscular electrical stimulation (NMES) of quadriceps to minimize muscle atrophy without stressing fixation.
  • Non-weight bearing or toe-touch weight bearing (approx. 10 kg), depending on surgeon’s recommendation and fixation stability.
• Precautions:
  • Avoid active knee flexion beyond surgeon’s prescribed range.
  • Limit weight-bearing according to fixation stability.
  • Monitor for signs of infection, fixation failure, or compartment syndrome.
• Exercises:
  • Isometric quadriceps and hamstring contractions Gluteal sets

Hip abductor isometrics

• • Ankle pumps and toe flexion-extension exercises to reduce venous thromboembolism risk Passive knee ROM within allowed limits.

• Goals:
  • Gradually increase knee ROM.
  • Begin partial weight bearing as tolerated.
  • Improve muscle strength and neuromuscular control.
  • Maintain cardiovascular fitness.
• Interventions:
  • Progress knee flexion gradually aiming for at least 90-120° of ROM by week 6.
  • Continuous passive motion (CPM) devices may be used, though evidence on impact is mixed
  • Begin partial weight bearing, typically progressing from toe-touch (~10 kg) to 20-30 kg as tolerated.
  • Continue NMES if needed.
  • Introduce hip abductor strengthening to assist knee joint loading and gait mechanics.
  • Soft tissue mobilization and gentle stretching.
  • Use of knee brace may continue if ligamentous injury or instability present .
• Precautions:
  • Avoid full weight bearing unless cleared by surgeon.
  • Avoid deep knee flexion or high impact activities.
  • Monitor for pain and swelling.
• Exercises:
  • Side-lying hip abduction.
  • Straight leg raises
  • Stationary cycling without resistance as tolerated

• Goals:
  • Achieve full knee ROM (0-130° or greater).
  • Progress to full weight bearing.
  • Improve muscle strength and endurance.
  • Restore normal gait pattern.
  • Enhance balance and proprioception.
• Interventions:
  • Advance weight bearing to full as tolerated; many patients achieve full weight bearing by 9-12 weeks.
  • Initiate closed kinetic chain exercises (e.g., mini squats within pain-free range)
  • Balance and proprioceptive training.
  • Gait training focusing on normalizing step length and cadence.
  • Low-level laser therapy
• Precautions:
  • Avoid high-impact activities.
  • Watch for swelling or increased pain indicating overloading.
  • Continue to protect fixation if fracture healing not confirmed radiographically.
• Exercises:
  • Partial squats (0-30°) progressing to full squats.
  • Step-ups and step-downs.
  • Stair climbing training
  • Hip abduction and extension strengthening.
  • Single-leg stance and balance exercises.
  • Cycling and swimming.

• Goals:
  • Restore full function and strength.
  • Return to vocational and recreational activities.
  • Optimize neuromuscular control.
• Interventions:
  • Advance to dynamic and plyometric exercises as tolerated.
  • Running progression and sport-specific drills for athletes.
  • Continued muscle strengthening focusing on quadriceps, hamstrings, and hip muscles.
  • Gait and balance re-training.
  • Address any residual deficits in ROM or strength.
• Precautions:
  • Avoid activities that cause pain or swelling.
  • Monitor for signs of joint instability or mechanical symptoms.
• Exercises:
  • Lunges, hops, and agility drills.
  • Resistance training with weights.
  • Endurance training.

• Goals:
  • Full return to pre-injury levels of activity.
  • Maintain joint health and function.
  • Prevent post-traumatic osteoarthritis.
• Interventions:
  • Maintain strength and conditioning program.
  • Regular functional assessments.
  • Patient education on joint protection strategies.
• Precautions:
  • Continued avoidance of extreme joint loading if advised.
  • Monitor for signs of degenerative changes.

• Early Weight Bearing: Recent studies challenge traditional delayed weight-bearing protocols and suggest that early or immediate weight bearing (as tolerated) after stable fixation may be safe and beneficial, leading to faster functional recovery without increased complication rates.
• Patient Compliance: Surveys indicate variability in surgeons’ weight-bearing recommendations and patient adherence is often poor; rehabilitation plans should incorporate patient education and objective weight-bearing monitoring where possible.
• Muscle Strengthening: Quadriceps and hip abductor strengthening are essential for optimizing knee joint biomechanics during gait and reducing the risk of long-term osteoarthritis.
• Use of CPM: Continuous passive motion devices are commonly used but their impact on outcomes remains unclear.
• Nutritional Support: Supplementation with vitamin D, calcium, and joint-supportive nutraceuticals (glucosamine, chondroitin) may aid bone and cartilage healing.

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