Annals of African Medicine
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Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 235-240  

Rehabilitation protocol after osteotomy of the tibia and varus femur - Case study

Research Center in Sports Sciences, Health and Human Development (CIDESD), Vila Real; Professor, Ministry of Education, Portugal

Date of Submission15-Apr-2020
Date of Acceptance01-Aug-2020
Date of Web Publication17-Sep-2021

Correspondence Address:
Prof. Sebastião Santos
CIDESD - Vila Real
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_29_20

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The knee rehabilitation in the aquatic environment has been used to start the rehabilitation of the lower limb earlier and improve joint movements, as it reduces pain and allows for earlier weight loading . The aim of the study was to develop and describe the effects of a therapeutic exercise program in an aquatic environment, in a clinical case of osteotomy of the tibia and the varus femur. A 15-year-old girl, submitted to an osteotomy of the tibia and the varus femur, completed a therapeutic exercise program in aquatic environment for a total of 30 sessions (3 sessions/week of 60 min). The subject was evaluated in two moments (at the beginning and at the end of the intervention ). The results showed an improvement in the various parameters evaluated (knee flexion: 66° vs. 125°, knee extension: −7° vs. −1°, and pain on movement: 6/10 vs. 0/10). We concluded the therapeutic exercise program in the aquatic environment used in this study had beneficial effects in the clinical case of tibial osteotomy and varus femur.

   Abstract in French 

La rééducation en milieu aquátique , est une solution pour commencer plus tôt la rééducation du membre inférieur et d´améliorer les mouvements articulaires , car il réduit la douleur et permet d´apliquer plus tôt une charge dans les exercices . L´objectif de l´études fût développer et décrire les effets d´un programme d´exercices thérapeutiques en milieu aquatique, dans un cas clinique d´ostéotomie du tibia et du varus fémur . Une jeune fille de 15 ans, soumise à une ostéotomie du tibia et du varus fémur , a suivi un programme d´exercices thérapeutiques en milieu aquatique dans un total de 30 séances (3 séances par semaine de 60 minutes ). Le sujet a été évalué en deux moments (au début et à la fin de l´intervention). Les résultas de l´étude nous indique une amélioration des diferents paramètres évalués (flexion du genou : 66° vs 125 °; extension du genou : -7° vs -1°; douleur au mouvement : 6/10 vs 0/10). Nous avons conclus que le programme d´exercices thérapeutiques aquatiques de cette étude a des effets bénefiques dans le cas clinique de l´ostéotomie du tibia et du varus fémur.

Keywords: Aquatic environment, case study, rehabilitation, therapeutic program, varization osteotomy
Mots-clés: Programme thérapeutique; Milieu aquatique, réhabilitation; étude de cas; Ostéotomie de varization

How to cite this article:
Santos S. Rehabilitation protocol after osteotomy of the tibia and varus femur - Case study. Ann Afr Med 2021;20:235-40

How to cite this URL:
Santos S. Rehabilitation protocol after osteotomy of the tibia and varus femur - Case study. Ann Afr Med [serial online] 2021 [cited 2023 Sep 24];20:235-40. Available from:

   Introduction Top

The normal functioning of the lower limbs is fundamental in the day-to-day activities of the human being. The knee joint complex becomes important due to its functionality, with its functions of distribution and cushioning of loads, the nutrition of the epiphyseal cartilages and the lubrication of the joint itself, has a great importance in joint stability. Ligaments are one of the most important components of the knee. Its main role lies in contributing significantly to resistance to abnormal knee movement, acting in conjunction with other static structures (bone-articular configuration, capsular structures and menisci) and with muscles, as dynamic stabilizers. Internal risk factors, external risk factors influence the load and its tolerance as well as the properties and size of the ligaments are influenced by age, sex, body size, and training.[1]

The occurrence of these deformities causes changes in the load/”weight” distribution at the knee joint, internal compartment in the varus knee and external compartment in the valgus knee. This mechanical overload causes cartilage wear, which by definition corresponds to arthrosis associated with rupture of the menisci. These tears are the most important and frequent factor in the source of pain felt by the patient. The new bone position is maintained by placing fixation material in the titanium or steel (usually titanium, allowing nuclear magnetic resonance to be performed), which will allow bone consolidation in the desired position. In this postoperative period, support of the lower limb may be limited or prohibited, for reasons inherent to surgery or treatment of associated injuries (meniscus or cartilage).

Aquatic exercise program

Aquatic physiotherapy can be safely applied in the early postoperative phase.[2] The progressive aquatic resistance training has positive effects in limiting mobility, increasing walking speed, and decreasing the time to climb stairs. In addition, training increases the muscle power of the lower limbs. Water resistance training is a viable mode of rehabilitation that has broad positive effects on patients after knee surgery.[3] Postoperative rehabilitation is to prepare the patient to return to preinjury activity levels, minimizing the risk of future injuries.[4] For elite athletes with acute ligament sprain in the lower limb, aquatic exercises can offer advantages over land-based therapy for a quick return to athletic activities. Consequently, aquatic exercise can be recommended for the initial phase of a rehabilitation program.[5]

Exercises in water become less painful than in a dry land,[6] facilitate movement due to decreased gravity. Water provides muscle relaxation as well as an analgesic effect relieving pain and spasm. In water, there is a request for a greater number of muscle groups in a single exercise, facilitating the reduction of load and effort at the joint level. Water-based exercises improve knee and hip flexibility, strength, and aerobic conditioning. The application of an aquatic rehabilitation program will be beneficial in the short term, although it may not offer an improvement in pain.[7]

   Case Study Top

The case study values the results obtained with the subject without, however, extrapolating them, has the objective of valuing the description of a situation, as well as the explanation of results, the identification of the relations between the cause and the effect,[8] without forgetting the decision making, convenient for the case study, making them very useful for analyzing, describing and illustrating the situations in a case record.[9]

Objective of the study

The study was developed with the objective of developing a protocol for a therapeutic exercise rehabilitation program in an aquatic environment. The initial draft was developed using expert opinions,[10],[11] after which it was applied in this case study.


The female participant at the age of 15 years underwent surgery for osteotomy of the tibia and the varus femur. Osteotomies of the tibia and femur, usually valgus and variant, respectively, are surgeries performed to correct deviations in the axis of the lower limbs, commonly described as crooked legs (knees in or out, also referred to, respectively, as genuine valgus or varus).


The research was conducted in accordance with international ethical guidelines and anonymity was preserved.

The intervention took place for 10 consecutive weeks, three times a week, for a total of 30 sessions. With the presence of the technical manager (rehabilitation in exercise medicine and Sports), the aquatic rehabilitation program [Appendix 1] was carried out in a 16.66 m water tank with a depth that varied from 0.90 m to 1.50 m with the water temperature between 28°C and 29°C.

The evaluations were carried out before and after the application of the aquatic rehabilitation program. The parameters evaluated in the two evaluation moments were as follows: Pain through the Visual Analog Scale. This scale consists of a horizontal or vertical line, 10 cm long, which has the “No Pain” classification on one end and the “Maximum Pain” classification on the other. The patient will have to cross the point representing intensity of your pain. Thus, there is equivalence between the intensity of the pain and the position marked on the straight line. The distance between the beginning of the line that corresponds to zero and the marked location is subsequently measured (in centimeters), thus obtaining a numerical classification that will be marked on the registration sheet (Normative Circular No. 9/DGCG, 2003).

Joint amplitudes were measured with the universal goniometer, according to the procedures indicated by Norkin and White.[12]

   Discussion Top

After the initial assessment, the main difficulties identified were pain on movement, restriction of knee joint amplitudes, changes in the muscular system, namely, decreased thigh muscle mass (compared to a contralateral limb), deficit of strength in the flexors and knee extensors and postural imbalance. [Table 1] shows the results obtained in the evaluation of knee joint amplitudes. In the 1st evaluation carried out, there was a limitation in the amplitudes of the right knee in relation to the left knee, mainly in flexion, in which the difference between the two limbs was 63°. The subject had some discrepancies in the left knee; however, throughout the treatment, the amplitudes of both knees evolved favorably, having achieved full extension and registering only a difference of 9° less in the flexion of the right knee, compared to the left.
Table 1: Evaluation of joint amplitudes (1st and 2nd evaluation moment)

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When looking at [Table 2], we can see that the pain values on movement, from the 1st moment to the 2nd moment, suffered a great reduction and that it was no longer present at the end of the evaluation.
Table 2: Assessment of pain on movement (1st and 2nd assessment moment)

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The results obtained point to an improvement in joint amplitudes, increased strength, improved balance, reduced pain on movement, and improved physical shape. The subject sees his clinical situation improved, as well as an improvement in his functionality, leisure, and quality of life. These results are in line with other studies that report significant improvements in aquatic work when compared to dry land.[2],[5],[13],[14] Distal femoral osteomotia offers the advantages of rapid pain reduction and short rehabilitation in young and active patients subjected to heavy knee loads.[15],[16] In this case study, the rehabilitation of the tibial and femur osteotomy was performed in an aquatic environment, following an exercise program, built by the author according to the bibliography and the preestablished objectives. The rehabilitation program followed a protocol [Appendix 1] in an aquatic environment defined by us, with the clinical picture evolving favorably, with improvements in all parameters evaluated, namely mobility, pain, muscle strength, balance, and knee functionality, like other studies.[3] The mobility acquired by the user went beyond what would be expected with a land-based rehabilitation. According to other studies with differentiated protocols but performed in an aquatic environment,[11] the range of motion of flexion is between values of 120° and 130°, with the user presenting these values in this case study. We can see that our results are quite significant, as well as other protocols[3] carried out in the context of water.

There is a belief that exercise can harm cartilage, creating a predominant barrier to the implementation of therapeutic exercises in the knee joint to be treated. The benefits of physical activity and therapeutic exercise go far beyond the improvement in pain, function, and quality of life of patients with knee problems (osteoarthritis).[17] A specific aquatic physiotherapy program for inpatients has a positive effect on early recovery of hip strength after joint replacement surgery.

   Conclusions Top

We developed and validated an aquatic rehabilitation protocol. The protocol demonstrated significant improvements in the evaluated parameters of pain and amplitude of the lower limbs. Our protocol includes instructions that are clear, easy, and applicable in rehabilitation settings. However, we expect further improvements and updates to our protocol from other researchers.

The results obtained showed an improvement in all aspects evaluated, namely pain, mobility, muscle strength, balance, and functionality of the knee. Thus, we can consider that the therapeutic exercise program in the aquatic environment had positive effects in this case of rehabilitation study after varization osteotomy.


The use of a control group would have reinforced the case study in question, bringing new results and probably obtaining conclusions that reinforced this protocol.

Ethical approval and consent to participate

The legal guardian and the subject were previously informed about the purpose of the intervention and the procedure and agreed and gave informed consent in accordance with the Declaration of Helsinki [Appendix 2]. Data confidentiality and anonymity were also ensured.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   Appendix 2 Top

Declaration of consent

Case study of a varization osteomomy

I, the undersigned (full name of the user), _________________________________________________________________________________________, have understood the explanation given to me about my clinical case and the intended research and the study in which I will be included. I was given the opportunity to ask the questions I deemed necessary, and all of them were answered satisfactorily. I understand that, in accordance with the recommendations of the Declaration of Helsinki, the information or explanation given to me concerned the objectives, the methods, the expected benefits, the potential risks and the possible discomfort. In addition, I have been informed that I have the right to refuse to participate in the study at all times, without prejudice to any assistance to me. Therefore, I consent to the method, treatment or inquiry proposed by the researcher.

Date: ___/___/___

Volunteer Signature: ______________________________________________

The investigator in charge: Signature: _________________________________Contd...

   References Top

Bahr R, Kraushaug T. Understanding injury mechanisms: A key component of preventing injuries in sport. Br J Sports Med 2005;39:324-9.  Back to cited text no. 1
Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: A randomized controlled trial. Arch Phys Med Rehabil 2009;90:745-55.  Back to cited text no. 2
Valtonen A, Pöyhönen T, Sipilä S, Heinonen A. Effects of aquatic resistance training on mobility limitation and lower-limb impairments after knee replacement. Arch Phys Med Rehabil 2010;91:833-9.  Back to cited text no. 3
Paterno M, Filipa A. Rehabilitation and return to sports after anterior cruciate ligament reconstruction in the young athlete. In: Parikh S, editor. The Pediatric Anterior Cruciate Ligament. Champagne: Springer; 2017. p. 183-98.  Back to cited text no. 4
Kim E, Kim T, Kang H, Lee J, Childers MK. Aquatic versus land-based exercises as early functional rehabilitation for elite athletes with acute lower extremity ligament injury: A pilot study. PM R 2010;2:703-12.  Back to cited text no. 5
Heywood S, McClelland J, Geigle P, Rahmann A, Villalta E, Mentiplay B, et al. Force during functional exercises on land and in water in older adults with and without knee osteoarthritis: Implications for rehabilitation. Knee 2019;26:61-72.  Back to cited text no. 6
Wang TJ, Belza B, Elaine Thompson F, Whitney JD, Bennett K. Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. J Adv Nurs 2007;57:141-52.  Back to cited text no. 7
Serrano G. Investigación Cualitativa. Retos e Interrogantes – I. Métodos. Madrid: Ed. La Muralla; 2004.  Back to cited text no. 8
Gomez R, Flores J. Jimènez E. Metodologia de la Investigacion Cualitativa. Malaga: Ediciones Aljibe; 1996.  Back to cited text no. 9
Santos S, Sarmento H, Alves J, Campaniço J. Construcción de un instrumento para la observación y el análisis de las interacciones en el waterpolo, Rev Psicol Deporte 2014;23:191-200.  Back to cited text no. 10
Jahan A, Dmitrievna M, Ismayilova M. Development and preliminary validation of a new protocol for postoperative rehabilitation of partial meniscectomy. J H Sport Exerc 2018;13:577-600.  Back to cited text no. 11
Norkin C, White J. Medida do Movimento Articular: Manual de Goniometria. Brasil: Artes Médicas; 1997.  Back to cited text no. 12
Lovecchio N, Sciumè L, Zago M, Panella L, Lopresti M, Sforza C. Lower limbs kinematic assesssment of the efect of a gym and hydroterapy rehabilitation protocol after knee megaprosthesis: A case report. J Phys Ther Sci 2016;28:1064-70.  Back to cited text no. 13
Jabbar K, Kudo S, Goh K, Goh M. Comparison in the three dimensional gait kinematics between young and older adults on land in shallow water. Gait Posture 2017;57:102-8.  Back to cited text no. 14
Yoo JD, Kim Nk. Distal femoral varization osteotomy. J Kor Orto Assoc 2014;43:118-25.  Back to cited text no. 15
Yoshioka T, Kubota S, Sugaya H, Hyodo K, Ogawaz K, Taniguchi Y, et al. Robotic device-assisted knee extensio training during the early postoperative period after opening wedge high tibial osteotomy: A case report. J Med Case Rep 2017;11:213-22.  Back to cited text no. 16
Bricca A, Roos EM, Juhl CB, Skou ST, Silva DO, Barton CJ. Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation. Br J Sports Med 2020;54:118-9.  Back to cited text no. 17


  [Table 1], [Table 2]


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