Variability in Postoperative Immobilization and Rehabilitation Following Reconstructive Hip Surgery in Nonambulatory Children With Cerebral Palsy

Abstract

Background: Despite being a common procedure, there are no standard protocols for postoperative immobilization and rehabilitation following reconstructive hip surgery in children with cerebral palsy (CP). The purpose of this study was to investigate variability in postoperative management and physical therapy (PT) recommendations among orthopaedic surgeons treating hip displacement in children with CP. Methods: An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopaedic surgeons. The case of a child undergoing bilateral femoral varus derotation osteotomies and adductor tenotomies was presented. Surgeons were asked to consider their typical practice and the case scenario when answering questions related to immobilization, weight-bearing, and rehabilitation. Recommendations with increasingly complex surgical interventions and different age or level of motor function were also assessed. Results: Twenty-eight orthopaedic surgeons from 9 countries with a mean 21.3 years (range: 5 to 40 y) of experience completed the survey. Postoperative immobilization was recommended by 86% (24/28) of respondents with 7 different methods of immobilization identified. All but 1 (23/24) reported immobilizing full time. Most (20/23) reported using immobilization for 4 to 6 weeks. Return to weight-bearing varied from 0 to 6 weeks for partial weight-bearing and 0 to 12 weeks for full weight-bearing. PT in the first 1 to 2 weeks postoperatively was reported as unnecessary by 29% (8/28) of surgeons. PT for range of motion, strengthening, and return to function was recommended by 96% (27/28) of surgeons, starting at a mean of 2.6 weeks postoperatively (range: 0 to 16 wk). Only 48% (13/27) reported all of their patients would receive PT for these goals in their practice setting. Inpatient rehabilitation was available for 75% (21/28) but most surgeons (17/21) reported this was accessed by 20% or fewer of their patients. Conclusions: Postoperative immobilization and PT recommendations were highly variable among surgeons. This variability may influence surgical outcomes and complication rates and should be considered when evaluating procedures. Further study into the impact of postoperative immobilization and rehabilitation is warranted.

Postoperative Immobilization After Hip Reconstruction in Cerebral Palsy: No Difference Between Hip Spica and Abduction Pillow

“…While hip spica casts were classically considered the standard for immobilization following hip reconstructive surgery in children with CP, there is evidence that satisfactory outcomes can be obtained with alternative methods of postoperative immobilization ( 19 , 24 , 25 ). Spica casts have been actively avoided by families and care teams familiar with them because they are cumbersome and associated with other challenges during care ( 26 ).…”

“…The stability of pelvic osteotomy techniques, when used, has also allowed many surgeons to view spica casting as optional. Miller et al recently showed that there is a tremendous lack of consensus in postoperative immobilization for CP hip reconstruction ( 19 ). This study sought to directly compare outcomes of hip reconstruction at a single institution in children that were immobilized with spica casts versus abduction pillows and better elucidate the complication rate of these methods.…”

“…Postoperative care strategies are highly variable between surgeons and institutions, with large differences in immobilization strategies, and this lack of consensus is in part due to the lack of substantial evidence directly comparing different methods of immobilization. Described alternatives have included long leg splints with abduction wedge, abduction wedge alone, Petrie cast, long leg splints alone, night splint foam, short leg casts with derotation bar and knee immobilizers, hip abduction orthosis, or no immobilization at all ( 19 ). The most common method outside spica casting at our institution is an abduction pillow, a commonly utilized method according to a recent survey by Miller et al ( 19 ) ( Figure 2B ).…”

“…Described alternatives have included long leg splints with abduction wedge, abduction wedge alone, Petrie cast, long leg splints alone, night splint foam, short leg casts with derotation bar and knee immobilizers, hip abduction orthosis, or no immobilization at all ( 19 ). The most common method outside spica casting at our institution is an abduction pillow, a commonly utilized method according to a recent survey by Miller et al ( 19 ) ( Figure 2B ). Length of immobilization was 6 weeks in spica cast, and 6 weeks in abduction pillow.…”

What's New in Orthopaedic Management in Neuromuscular Disorders

“…Another area of high variability is the varied postoperative immobilization techniques and protocols among surgeons. 25 The recovery from hip reconstruction and spine surgery is painful, with short-term improvements in Health Related Quality of Life (HRQoL) and caregiver burden. 26 After 5 years, the improvement in HRQoL and caregiver burden is maintained after hip reconstruction but declines to pre-surgical baseline after spine fusion.…”