Role of early motion in healing fractures and ligaments realized in last 25 years

Influence of early mobilization endures, is used in knee ligament injuries, fracture care, back injuries.

Issue: January 2005

This patient's knee is shown in full hyperextension during a postop exam where the femur is being held down while the foot is being lifted off of the table. Hyperextension should always be compared to the uninjured knee, according to K. Donald Shelbourne.

COURTESY OF K. DONALD SHELBOURNE

The idea of moving a fractured limb soon after injury — or using a joint within days or hours of an operation — went against accepted medical practice when it was introduced. But orthopedists who first adopted early mobilization found that outcome improved when joints were mobilized after fracture repair, patients skipped extended bed rest, and rehabilitation and physical therapy began shortly after treatment.

Some of the innovators in early motion and mobilization told Orthopedics Today these same principles are now being applied in other areas, such as hip arthroscopy, shoulder tendon repair and total hip replacement. Research continues to demonstrate that moving a limb or joint aids rehabilitation and leads to a better outcome. One innovator called it one of the most important medical advances in his lifetime.

Early innovations

Augusto F. Sarmiento, MD, of Coral Gables, Fla., past president of the American Academy of Orthopaedic Surgeons, was one of the early innovators in this area, first applying these principles to amputees and later to his fracture patients.

During hundreds of below knee amputations, Sarmiento applied a prosthesis before the patient left the operating room, a procedure pioneered by Marion Weiss, MD, Warsaw, Poland. “It was those experiences with amputees that one day prompted me to believe it might work in treating fractures of the tibia, using a cast that resembled the patella-tendon bearing or PTB prosthesis,” he told Orthopedics Today.

Sarmiento had seen patients develop stiffness when their knee was immobilized following a tibia fracture. He realized he could safely free the knee and ankle when treating fractures of the tibia, a simple change that greatly affected outcome. In July 1967 Sarmiento and his colleagues published their results using this technique — now known as functional bracing — in closed fractures.

“In less than a year I came to the conclusion that the thing worked, that I did not have to immobilize the ankle or knee,” he said.

This patient demonstrates how the below-the-knee functional brace he wore following a tibial fracture allowed his knee and ankle joints to maintain a full range of motion. This approach was one that early rehabilitation innovators found improved outcomes and reduced joint stiffness and the onset of arthritis.

These before and after radiographs show the initial appearance of humeral fracture (left) and how the extreme deformity was spontaneously corrected after a brace was applied and passive pendulum exercises were begun.

COURTESY OF AUGUSTO F. SARMIENTO

Early activity

According to Vert Mooney, MD, medical director of U.S. Spine & Sport in San Diego, British orthopedists first advocated immobilization. “[Immobilization was applied to] most of all medicine practiced in the 50s. … But only as time has passed has it become clear that activity is good.”

Mooney, who was Vernon L. Nickel’s fellow at Rancho Los Amigos Medical Center in Downey, Calif., conducted early experiments on rabbits, exploring the effects of early motion to determine the optimal time to move a joint postoperatively. “It became quite clear that early motion was better than delayed motion,” he told Orthopedics Today in an interview.

Results of a study Mooney conducted involving 100 patients with femoral fractures supported this finding. Spica casts were placed on 50 patients, the standard of treatment at the time, and the other patients wore a cast brace and could walk on their affected leg. The group treated with the new protocol did a lot better, he said. “It started the pendulum swinging in the right direction relative to fracture care.”

Mooney said he applies these same rehabilitation techniques in his spine patients.

Better healing

David F. Apple, MD, director of the Shepherd Center, Atlanta, and editor of Orthopedics Today’s rehabilitation section, said he vividly remembers when Sarmiento showed him “that early mobilization of people with fractures promoted healing. This … made everyone start thinking that maybe rest isn’t the best thing for it, that resuming function of an injured extremity or a diseased extremity or spine would be more productive in achieving a good outcome.”

“A patient that broke their back used to be in bed for three months with all the deconditioning that went along with that and the atrophy and loss of muscle power. Now most patients with spine injuries, with the better instrumentation we have, can be mobilized and returned to activity within a matter of weeks,” Apple said.

Early mobilization not only enhanced the injured area, “but also it kept you from losing function in the noninjured parts. So I think that’s been a real boon to recovery,” he said.

The patient's humeral fracture healed well based on these anteroposterior and lateral radiographs.

A functional humeral fracture brace is shown here. A sling is initially worn in conjunction with it to support the arm.

COURTESY OF AUGUSTO F. SARMIENTO

Exercising early

Early mobilization has had a significant impact on fracture care, knee ligament surgery, cartilage repair and spine care. Mooney said that immobilization was widely used when anterior cruciate ligament (ACL) surgeries were first performed. The approach eventually changed so that the emphasis was on exercising the injured or operated knee to build up the muscles. “Thereafter, progressive resistance exercises for the knee became the standard of care,” he said.

K. Donald Shelbourne, MD, of Indianapolis, Ind., has operated on knee ligaments in thousands of patients, mainly athletes. He said that the patients should first regain motion “and then secondarily maintain stability. That has to be secondary to motion, because in ACL surgery — no matter what graft, fixation, rehabilitation program or protocols you use — you have to get symmetric motion back or else the patient will not have a normal knee.”

Shelbourne, who recently began a solo practice that includes four physical therapists skilled in knee rehabilitation, said patients show concern about having symmetrical knees and become unhappy when that does not occur. So for him, early motion following ACL surgery means meeting the patient’s goals for a satisfactory postoperative result, whatever that takes. “Your whole goal is to make people symmetric again, and if surgery is needed to allow you and your therapist to get them symmetric, well then it’s a necessary evil.”

Follow-up

Ten days after injury the surgeon applied a functional brace to treat this male patient's axially unstable fracture of the tibia. At left, he stands on a force plate which measures the weight he applied with his injured leg according to his symptoms. Data pertaining to his leg shortening during weight-bearing is detected by motion recording cells and transmitted to a computer. These radiographs (right) showed the initial shortening to be clinically acceptable.

Shelbourne has done extensive follow-up of patients to evaluate the efficacy of early mobilization. Three hundred forty-five patients have been followed a minimum of 10 years, and all patients he now sees are routinely followed up with a questionnaire and examination. Based on their results, Shelbourne believes he has surpassed most practitioners’ application of the principles of early motion and rehabilitation.

Shelbourne agrees that the general thinking shifted when Sarmiento started doing fracture bracing. “Why would you restrict somebody from doing something unless it was harmful? What we found was that moving after ACL reconstruction wasn’t harmful.

“Early motion isn’t any good unless you get full motion,” Shelbourne said. “That’s the biggest thing I’ve learned in the last 10 years. It doesn’t matter if I move them early or not … only if I eventually obtain symmetrical full motion in the person’s knee.”

Motion promotes healing

J. Richard Steadman, MD, of Vail, Col., saw how well early motion worked in cases of fractures and ligament surgery and applied it to microfracture, his cartilage regeneration technique. “My feeling was that with the general sense of mobility being a good thing, we would employ mobility in this cartilage regrowth.”

Steadman told Orthopedics Today that the concept of early motion promoted in Switzerland in the late 1960s affected his own practice. “It was found that if the fracture was solidly immobilized, [early mobilization] in fact allowed for better joint function and better long term results. … In the ligament area, I concluded that if the motion didn’t deform the ligaments, it would be desirable in their healing,” he said.

Early motion with Steadman’s microfracture technique involves continuous passive motion six to eight hours a day for up to eight weeks beginning on the day of surgery. Like ligaments, cartilage needs to receive a mechanical message instructing it to become a new cartilage layer, Steadman said. “It made sense to me that the mechanical message … for this deforming cartilage to get … would be one of protection and motion to form a smooth gliding surface.”

Apple said this innovation in rehabilitation was one of the most important medical advances in his lifetime. “When the primary healing has taken place, you’re starting out with a much enhanced situation for making improvement happen … in knee ligament injuries, fracture care, back injuries. It has been a great revolution.”