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Varus Derotation Osteotomy

These protocols are for physiotherapy following varus derotation osteotomy, and varus derotation osteotomy and pelvic osteotomy.

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

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
  • 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


SOURCE: Varus Derotation Osteotomy ( )
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