Please note that this is advisory information only. Your experiences may differ from those described. All exercises must be demonstrated to a patient by a fully qualified physiotherapist. We cannot be held liable for the outcome of you undertaking any of the exercises shown here independently of direct supervision from Integrum Physiotherapy.
We recognise that DDH patients make up a broad and often complex patient group and therefore needs an individualised rehabilitation approach. Our emphasis is on patient-specific rehabilitation, which encourages recognition of those patients who may progress slower than others. These rehabilitation guidelines are therefore ‘milestone driven’ and designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the outpatient clinic by helping the patient and therapist to identify when specialist review is required.
These guidelines have been written to help aid Physiotherapists who are treating post-operative Peri-acetabular osteotomy patients and also guide patients on what the rehabilitation will involve.
Indications for Surgery
The main indication for a peri-acetabular osteotomy is developmental dysplasia of the hip, where the acetabulum is too shallow and does not provide adequate coverage for the femoral head.
· Wound healing/infection
· Blood loss-requiring transfusion
· Delayed union or non-union
· Loosening of fixation
· Leg length discrepancy
· Rarely-neuropraxia/nerve damage
A peri-acetabular osteotomy is performed around the affected acetabulum. The acetabulum is re-orientated to provide greater coverage for the femoral head. It is secured in place with two-three threaded pins until bony healing occurs.
· Functional outcome is heavily dependent upon the pre-operative condition of the hip joint.
· Pre-existing damage and arthritis of the hip can have a significant negative affect upon functional outcome.
· Post-operative rehabilitation is vital to ensure optimum functional outcome.
· May take 6 months- 1 year to achieve optimal function.
· ROM at hip back to pre-operative level.
· Mobilises independently mobile, with no aids.
Main muscles affected:
· Hip flexors
· Hip abductors due to pain inhibition
· Can see hypertrophy of TFL
The patient may be seen pre-operatively, and with consent, the following can be assessed:
Always check the operation notes, and the post-operative instructions. Discuss any deviation from routine guidelines with the team concerned.
INITIAL REHABILITATION PHASE: In-patient Stay (Usually 4-6 days)
· Swelling management - After PAO, there is a variable amount of pain and swelling, often depending on how much surgery was done. This usually diminishes after several weeks. It is helpful to keep the leg elevated above your heart and to apply ice regularly.
Active range of movement exercises for the hip.
Closed chain hip flexion (heel slides NO straight leg raise), supine hip abduction/adduction, standing sliders hip abduction and extension adhering to 20kg WB.
Gait re-education: Ensure safely and independently 20kg partial flat foot weight-bearing with walking aids.
· Knee/hip and ankle range of movement exercises
· Strengthening- Maintain hip range of movement within restrictions. Commence isometric glutes, inner range quads (avoid LRQ’s for 2-3 weeks due to activation of rec fem), closed chain standing slider exercises into flexion/ext/abd maintain 20kg weight-bearing.
· Pacing adviceas appropriate.
On discharge from the ward
Initial rehabilitation phase post discharge from hospital-6 week review.
· Wound infection.
· Nerve damage.
· Non-union-rotation of osteotomy back to original position.
· Prone lying may be commenced from 2 weeks post operatively to encourage small stretch of anterior capsule and hip flexors.
· Trans abs activation to encourage improved core stability.
· Commence bent knee fall out once patient can activate trans abs.
· Can add exercise bike after 2 weeks with no resistance starting at 30-70 hip flexion, progressing to 0-70 degrees as tolerated, by week 4 able to do 20 mins.
· Isometric glutes
· Can add long range quadriceps from 3 weeks post op.
· Closed chain standing slider exercises into flexion/ext/abd maintain 20kg weight-bearing.
· Potential Hypertrophy of TFL
· If there is persistent fever, a sudden increase in pain or swelling, wound redness or oozing, heat around incision site, increasing numbness, calf pain/swelling, or shortness of breath the patient should be reviewed urgently by the medical team.
Milestones to progress to next phase
· At the first outpatient review the assessment will focus wound healing and evidence of bony healing at the osteotomy sites. Once radiographic evidence of bony union has been observed then the weight-bearing status can gradually be increased over the next 6 week period.
· No or minimal hip pain.
6-12 WEEKS POST-OPERATIVE REHABILITATION PHASE:
· Return to full weight bearing as per consultant guidelines.
· Commence loading programme
Example exercises: Cycling, Cross trainer, commence double leg loading as able, isometric glute med with belt- bridging and sit to stand.
· Alter-G treadmill (If available) –especially relevant at 25%-75% weight bearing as can start normalisation of loading tissues and bone at weight bearing status.
Ø Strengthening of other muscle groups as appropriate.
Core stability and gluteal control work
Stretches– maintain stretches as appropriate to ensure normal flexibility of hip flexors, obliques, quadriceps, hamstrings and calf muscles in weight bearing position.
Hydrotherapy (if available)- especially relevant at 25%-75% weight bearing as can start normalisation of loading tissues and bone at weight bearing status.
Milestones to progress to next phase
· Healing evident on x-rays (superior pubic ramus, ilium & ischium).
· Full, pain-free hip ROM
· No evidence of hip flexor inflammation
· Good muscle patterning and recruitment of glute med with minimal TFL dominance.
· Pain free gait with correct patterning with/without aids.
· Hip flexion strength >70% of non-operated side.
· Hip add, abd, ext, IR, ER strength >80% of non-operated side.
12 WEEKS-6 MONTHS POST-OPERATIVE REHABILITATION PHASE:
• Full pain-free ROM
• Increase loading of bilateral exercises in gym
• Increase volume of single leg loading
• Commence gentle running drills and plyometrics if comfortable from week 15-20.
· Return to normal function- ADL’s, return to work, driving, school etc.
· Advice and Education- on return to sport (expected from around 6 months post op) and normal function.
· Mobility- Independently mobile.
· Exercises: Can commence open chain work as long as correct muscle patterning occurring (monitor for TFL overload/hypertrophy). Progress to impact/plyometric based exercise when ready.
· Progress swimming as comfort allows
· Commence jogging and progress running distance
· Initiate sport-specific drills as appropriate
· Gradual return to sports participation
· Maintenance program for global strength and endurance
Milestones for discharge
Failure to meet milestones
Failure to progress
If a patient is failing to progress, then consider the following:
Ensure elevating leg regularly.
Use ice as appropriate if normal skin sensation and no contraindications.
Use walking aids.
Modify exercise programme as appropriate.
If does not decrease over a few days, refer back to surgical team
Ensure adequate analgesia.
Pacing discussion and modify exercise programme as appropriate. Should continue isometric work at all times.
If persists, refer back to surgical team.
Breakdown of wound e.g. inflammation, bleeding, infection
Refer to surgical/CNS team.
Alert surgical team immediately
Summary of evidence for physiotherapy guidelines
A comprehensive literature search was carried out to identify research relating to rehabilitation following Peri-acetabular Osteotomy.
· Adler, K.L. et al (2015) ‘Current Concepts in Hip Preservation Surgery: Part II—Rehabilitation,’ Sports Health: A Multidisciplinary Approach, 8(1), pp.57-64.
· Abbas, C., and Daher, J. (2017) ‘Pilot study: Post-operative rehabilitation pathway changes and implementation of functional closed kinetic chain exercise in total hipand total knee replacement patient,’ Journal of Bodywork and Movement Therapies, 21(4), pp.823-829.
· Belavy, D.L., Bock, O., Borst, H., et al, (2010) ‘The second Berlin Bedrest study: protocol and implementation,’ Journal of Musculoskeletal Neuronal Interaction, 10 (3), pp. 207-219.
· Clohisy, J.C., Schutz, A.L., St.John, L., et al, (2009) ‘Periacetabular Osteotomy: A systematic Literature Review,’ Clinical Orthopaedics and related research, 467(8), pp. 2041-2052.
· Davy DT, Kotzar GM, Brown RH, et al. Telemetric force measurements across the hip and after total arthroplasty. J Bone Joint Surg. 1988; 70A:45–50.
· Ito, H., Tanino, H., Sato, T., et al, (2014) ‘Early Weight-bearing after periacetabular osteotomy leads to a high incidence of postoperative pelvic fractures,’ BMC Musculoskeletal Disorders, 15:234, pp.
· Meftah, M., Ranawat, A.S., Ranawat, A.S., Caughran, A.T. (2018) ‘Total Hip Replacement Rehabilitation: Progression and Restrictions,’ in Clinical Orthopaedic Rehabilitation, Philadelphia:Elsevier, pp.436-442.
· Schmitz, R.J., Riemann, B.L., and Thompson, T. (2002) ‘Gluteus Medius activity during isometric closed-chain hip rotation,’ Journal of Sport Rehabilitation, 11(3), pp. 179-188.
· Trundelle-Jackson, E., and Smith, S. (2004) ‘Effects of a Late-Phase Exercise Program After Total Hip Arthroplasty: A Randomized Controlled Trial,’ Archives of Physical Medicine and Rehabilitation, 85, pp. 1056-1062.
· Yang, J., Zhang, Z., and Cheng, H. et al, (2018) ‘Sciatic and femoral nerve injury among patients who received Bernese peri-acetabular osteotomy,’ International Orthopaedics, pp.1-5.