What is the recommended post-operative ambulation protocol for a patient with a knee fracture?

Post-Operative Ambulation Protocol for Knee Fracture Patients

Begin ambulation within 24 hours of surgery with weight-bearing as tolerated, combined with immediate knee mobilization and isometric quadriceps exercises to optimize functional recovery, reduce complications, and shorten hospital stay.

Immediate Post-Operative Phase (0-24 Hours)

Weight-Bearing and Ambulation

• Initiate ambulation within 24 hours post-operatively to achieve optimal outcomes 1, 2, 3, 4, 5
• Progress weight-bearing as tolerated within the first week, though this should be individualized based on fracture pattern and fixation stability 6, 7, 8
• Early ambulation (within 24 hours) reduces deep vein thrombosis risk by 30-fold compared to delayed mobilization 1
• Patients who ambulate within 24 hours demonstrate 1.8 days shorter hospital stay, lower costs, and improved knee function 3, 4, 5

Early Mobilization

• Begin immediate knee mobilization within the first week to increase joint range of motion, reduce knee pain, and prevent extension deficits 6, 7, 8
• Start isometric quadriceps exercises (static contractions, straight leg raises) in the first postoperative week if they cause no pain 6, 7, 8
• Apply cryotherapy immediately after surgery to reduce knee pain and swelling without increasing risk of adverse events 6, 7, 8

Critical First 24-Hour Goals

• Achieve sitting position (typically by day 2-3 with early protocols) 2
• Progress to standing position (typically by day 2-3) 2
• Complete first assisted ambulation (typically by day 2-3) 2
• Maintain pain scores below 4/10 with appropriate analgesia 2

Days 2-14: Early Protection Phase

Exercise Progression

• Continue isometric quadriceps exercises if well-tolerated without pain or effusion 7, 8
• Begin closed kinetic chain exercises (leg press, squats, step-ups) from week 2 onward 7, 8, 9
• Prioritize closed kinetic chain over open kinetic chain exercises to minimize stress on healing fracture 7, 8, 9
• Consider neuromuscular electrical stimulation (NMES) for 6-8 weeks to re-educate voluntary quadriceps contraction 6, 7, 8

Ambulation Advancement

• Progress from assisted to independent ambulation with appropriate assistive device 4
• Aim for patients to require walking aids with smaller base of support as strength improves 4
• Continue supervised physiotherapy with progression based on fracture healing and patient tolerance 8

Weeks 2-6: Moderate Protection Phase

Strengthening Protocol

• Transition from isometric to concentric and eccentric exercises when quadriceps is reactivated and knee shows no effusion or increased pain 8
• Maintain emphasis on closed kinetic chain exercises for first 6-8 weeks 7, 8
• Begin leg press at 3 weeks to improve subjective knee function 7
• Cautiously introduce open kinetic chain exercises (90-45°) at 4 weeks minimum, but only if fracture healing permits 6, 7, 8

Functional Goals

• Achieve at least 90 degrees of knee flexion 4
• Progress basic activities of daily living 7
• Maintain pain control below 3/10 2

Weeks 6-12: Minimum Protection Phase

Advanced Strengthening

• Advance to both open and closed kinetic chain exercises with progressive resistance 7, 8
• Implement eccentric training components for greater strength gains and quadriceps hypertrophy 7
• Combine strength training with neuromuscular/motor control training to restore dynamic stability 7, 8, 9
• Gradually increase ROM in open kinetic chain exercises: 90-30° (week 5), 90-20° (week 6), 90-10° (week 7), full ROM (week 8) 8

Months 3-6: Return to Function Phase

Objective Criteria for Progression

• Base advancement on objective criteria rather than time alone 7, 8, 9
• Achieve limb symmetry index >90% for strength testing before advancing to higher-level activities 7, 8, 9
• Ensure no pain, swelling, or instability on examination 7
• Perform isokinetic quadriceps and hamstring peak torque testing at 60°/s demonstrating 100% symmetry 7
• Assess countermovement jump and drop jump with >90% symmetry 7
• Evaluate patient-reported outcomes including subjective knee forms and psychological readiness 7, 8

Critical Pitfalls to Avoid

• Delaying mobilization beyond 24 hours significantly increases DVT risk (27.6% vs 1.0%), prolongs hospital stay, and increases costs 1, 3, 4, 5
• Failing to initiate immediate knee mobilization within first week leads to stiffness and extension deficits 6, 7, 8
• Advancing to aggressive open kinetic chain exercises before 4 weeks risks compromising fracture healing 6, 7, 8
• Neglecting neuromuscular training alongside strength training increases reinjury risk 7, 8
• Using time-based rather than criteria-based progression to higher-level activities 7, 8
• Discontinuing rehabilitation before 9-12 months may compromise optimal functional recovery 8