Quadriceps Reconstruction with Mesh or Allograft Following TKA
Quadriceps Reconstruction Mesh or Allograft
Postoperative Physical Therapy Protocol
General Considerations
This protocol addresses patients who have undergone TKA with quadriceps reconstruction using mesh or allograft tissue, often due to chronic extensor mechanism failure, tendon rupture, or poor tissue quality.
The protocol is intentionally more conservative to protect the graft while balancing the need to prevent postoperative stiffness common in TKA patients.
Progression is based on healing constraints of the reconstruction, not standard TKA timelines.
Phase I – Protective Phase (Weeks 0–4)
Goals:
Protect reconstruction site
Minimize inflammation and swelling
Prevent stiffness while preserving full extension
Begin neuromuscular activation (VMO emphasis)
Precautions / Restrictions:
Weight Bearing: WBAT with brace locked in full extension (0–0°)
Brace: Locked at 0–0° at all times during ambulation
Range of Motion (ROM):
Weeks 0–2: No ROM
Weeks 2–4: Passive ROM only, 0–20°
Therapeutic Exercises:
Ankle pumps
Isometric quadriceps sets (with NMES or biofeedback)
Hamstring and calf stretching (to maintain extension)
Patellar mobilization (gentle medial glides)
Leg raises in multiple planes (except hip flexion)
Core and contralateral limb strengthening
Cardiovascular:
Upper Body Ergometer
Well-leg cycling
Manual Therapy:
Soft tissue mobilization to surrounding musculature only
Effleurage for edema management
Avoid contact with surgical portals or “no-touch zone” (2 inches around graft)
Phase II – Limited Motion Phase (Weeks 4–6)
Goals:
Continue protection of reconstruction
Gradually reintroduce ROM
Maintain quadriceps and gluteal activation
Improve mobility without stressing graft
Precautions / Restrictions:
Brace: Continue locked in extension during ambulation
ROM:
Advance passive ROM to 0–50° by end of Week 6
No active flexion until cleared
Therapeutic Exercises:
Seated assisted heel slides within range
Quad sets with NMES
Standing hip abduction/adduction (band resistance proximal to knee)
Straight-leg bridging with brace on
Standing calf raises
Balance drills (double leg stance, no perturbation)
Manual Therapy:
Soft tissue mobilization around patellofemoral joint and suprapatellar pouch
Portal/scar mobilization if incisions fully healed
Phase III – Progressive Motion and Strength (Weeks 6–10)
Goals:
Achieve 90° of flexion without stressing graft
Begin active range of motion and closed-chain strength
Normalize gait mechanics
Precautions / Restrictions:
Brace: May unlock brace gradually per MD approval
ROM: Advance active-assisted ROM to 0–90°
Therapeutic Exercises:
Wall slides (0–90° limit)
Stationary bike (no resistance)
Double leg bridges
Mini step-ups
Terminal knee extensions (short arc quads)
Supported treadmill walking
Manual Therapy:
Patellar glides
Soft tissue mobilization to quads, IT band, lateral retinaculum
Phase IV – Reconditioning Phase (Weeks 10–16)
Goals:
Restore full ROM
Improve quad strength and symmetry
Introduce unilateral loading and dynamic balance
Therapeutic Exercises:
Full ROM cycling (add resistance)
Leg press (0–60° arc)
Mini squats, lateral step-ups
Single-leg balance drills
Begin pool-based gait and light resistance drills
Elliptical if pain-free
Manual Therapy:
Patellar taping if indicated for tracking
Joint mobilization for stiffness
Phase V – Return to Function (Months 4–6)
Goals:
Maximize strength, endurance, and proprioception
Begin return to recreational and low-impact athletic activities
Normalize gait and functional movements
Therapeutic Exercises:
Eccentric strengthening: leg press, decline squats
