Varus derotation osteotomy & soft tissue releases

Notes:

• VDRO will result in a leg length discrepancy if done only on one side
• Expect hamstrings length to be functionally increased; femoral shortening occurs with varus osteotomy resulting in improved hamstring ROM
• Despite adductor release, abduction range of motion (ROM) may not be significantly increased; surgical correction during the VDRO takes away the abduction range

Phase 1: Post-op Day 1 to 7

Goals: Pain management, equipment, early mobilization, discharge, and transition to home

• Adjust seating, as necessary, to support legs
• Family to be taught transfers – sliding board, manual, or mechanical lift
• Passive ROM /AAROM to joints not restricted in cast
• Ankle plantarflexor stretches, if required
• Hip flexion should not be limited with VDRO only

Phase 2: Post-op Day 8 to 4-6 weeks (until cast removal)

Goals: Maintain joint ROM, mobilization

• ROM – PROM/AAROM to joints not restricted in cast
• Consider alternate positions
• Avoid windswept posturing during the healing process
• Consider lying on the stomach; required if psoas/iliopsoas release
• Frequent position changes to prevent pressure areas
• Isometric contraction of glutei, quadriceps, and hamstrings, if able

Phase 3: Post-op 4- 6 weeks to 3 months

Reminder: Progression of these activities will be confirmed in the child’s post operative appointment

Goals: Hip and knee ROM, return to pre-op function

Positioning:

• Child may experience increased spasms/discomfort when cast removed and greater movement is allowed
• Use of the hip abduction splint for this transition may be helpful e.g. may choose to use splint for stability during transfers
• Use resting splint or pillow throughout the night for 3 months and during the day when napping, floor/sitting activities (e.g. watching television)
• Out of brace for functional mobility during the day
• Return to regular wheelchair seating with pommel

ROM:

• All hip ROM restrictions removed – confirm with orthopedic team

• PROM and AAROM of all LE joints; work towards full LE ROM in all planes; do not force range
• Consider stretching the following:
  • Adductors
    • Hip in extension (ie supine) - with knee extension and knee flexion (frog leg position)
    • Hip in flexion - with knee extension and knee flexion
    • Ring or cross leg sitting for play
  • Hip flexors
    • Lying on stomach
  • Hamstrings
• Scar mobility as required

Returning to Activity:

• Begin pool therapy program for ROM, strengthening, and initiation of weight bearing –confirm WB with orthopaedic team
• Expect to progress to partial weight bearing with walker during this time, even if not used pre-operatively, to establish good postural habits, and avoid early compensation - confirm WB with orthopaedic team

Phase 4: Greater than 3 months

Goals: Return to full weight bearing, return to full activity 

Positioning:

• Use of night splint/pillow may be discharged depending upon radiological findings, tone, range of motion
• Ensure hip abduction range of motion is maintained; consider continued use of splint/pillow for daily stretching

Activity Progression:

• Initiate weight bearing if not already done; begin to ambulate with walker even if not used pre-operatively to establish good postural habits and avoid early compensation – confirm WB with orthopaedic team
• Evaluate need for shoe raise due to shortening which occurs with femoral osteotomy (if unilateral)
• Start with endurance exercises with low load, high repetition; progress to strengthening exercises with mild resistance
• Strength training – hip abductors and extensors and knee flexors and extensors
• Gait training
• Balance training

Varus derotation osteotomy & pelvic osteotomy with soft tissue releases

Notes:

• VDRO will result in a leg length discrepancy if done only on one side
• Expect hamstrings length to be functionally increased; femoral shortening occurs with varus osteotomy resulting in improved hamstring ROM
• Despite adductor release, abduction range of motion (ROM) may not be significantly increased; surgical correction during the VDRO takes away the abduction range

Phase 1: Post-op Day 1 to 7

• Adjust seating, as necessary, to support legs
• Family to be taught transfers – sliding board, manual, or mechanical lift
• Passive ROM /AAROM to joints not restricted in cast
• If in Petrie cast, hip flexion may be restricted to between 30 and 60º - confirm with orthopaedic team
• Ankle plantarflexor stretches, if required

Phase 2:Post-op day 8 to 6 weeks (until cast removal)

Goals: Maintain joint ROM, mobilization

• ROM – PROM/AAROM to joints not restricted in cast<
• If in Petrie cast, hip flexion may be restricted to between 30 and 60º - confirm with orthopaedic team
• Consider alternate positions
• Avoid windswept posturing during the healing process
• Consider lying on the stomach; required if psoas/iliopsoas release
• Frequent position changes to prevent pressure areas
• Isometric contraction of glutei, quadriceps, and hamstrings, if able

Phase 3: 6 weeks to 3 months 

Reminder: Progression of these activities will be confirmed in the child’s post operative appointment

Goals: Hip and knee ROM, initiate weight bearing

Positioning:

• Child may experience increased spasms/discomfort when cast removed and greater movement is allowed
• Use of the hip abduction splint for this transition may be helpful e.g. may choose to use splint for stability during transfers
• Use resting splint or pillow throughout the night for 3 months and during the day when napping, floor/sitting activities (e.g. watching television)
• Out of brace for functional mobility during the day
• Return to regular wheelchair seating with pommel

ROM:

• All hip ROM restrictions removed – confirm with orthopaedic team
• PROM and AAROM of all LE joints; work towards full LE ROM in all planes; do not force range
• Consider stretching the following:
  • Adductors
    • Hip in extension (ie supine) - with knee extension and knee flexion (frog leg position)
    • Hip in flexion - with knee extension and knee flexion
    • Ring or cross leg sitting for play
  • Hip flexors
    • Lying on stomach
  • Hamstrings
• Scar mobility as required

Returning to Activity:

• Begin pool therapy program for ROM, strengthening, and initiation of weight bearing –confirm WB with orthopaedic team
• Expect to progress to partial weight bearing with walker during this time – confirm WB with orthopaedic team

Phase 4: Greater than 3 months

Goals: Return to full weight bearing, return to full activity

Positioning:

• Use of night splint/pillow may be discharged depending upon radiological findings, tone, range of motion
• Ensure hip abduction range of motion is maintained; consider continued use of splint/pillow for daily stretching

Activity Progression:

• Initiate weight bearing if not already done – confirm WB with orthopaedic team
• Evaluate need for shoe raise due to shortening which occurs with femoral osteotomy (if unilateral)
• Start with endurance exercises with low load, high repetition; progress to strengthening exercises with mild resistance
• Strength training – hip abductors and extensors and knee flexors and extensors
• Gait training
• Balance training