rehabilitation guidelines after periacetabular osteotomy...
TRANSCRIPT
Rehabilitation
Guidelines after
Periacetabular
Osteotomy
(PAO)
March 2017
Bobby Jean Lee, PT, DPT, SCS, CSOMT, CSCS, USAW
Texas Health Sports Medicine
Fort Worth, TX
To discuss the patient criteria for selection for a PAO procedure
Describe the surgical procedures utilized for PAO
Discuss the rehabilitation guidelines implemented after PAO
Objectives
Classifying Hip Pain
Classifying hip pain:
Non-hip disorders with referred pain
Extra-articular hip disorders
Intra-articular disorders without
structural abnormality
Structural abnormalities
Advance intra-articular disorders
Clohisy et al, 2005
Indications for Hip Preservation
Surgery
Age < 40 yo
Epiphyseal plates closed
Acetabular dysplasia present
Hip flexion ROM > 100°
OA
Mild to moderate OA in those with well preserved hip ROM and joint
congruency
Clohisy et al, 2005; Pogliacomi et al, 2005
Contraindications for Hip
Preservation Surgery
Lack of congruency between
acetabulum and femoral head
Open physes
Complete dislocation
Advanced OA
Advanced age at which time a THA
would give good results
Imaging Indications
A/P and Lateral Rx Views:
Pelvis
Increased acetabular
retroversion (cross over sign)
Normal = 15°-20° of
anteversion
Acetabular protrusion
Measurements:
Tonnis angle (AI):
Normal < 10°
Abnormal ≥ 15°
Center edge angle of Wiberg:
Normal > 25°
Dysplasia < 15°
Nunley et al. 2011
Mechlenburg et al. 2007
Labral Involvement
Almost 50% prevalence of labral tear in those with mild to moderate
dysplasia
Majority anterior tears
Few posterior or lateral tears
No isolated posterior or lateral tears
McCarthy et al, 2001; Peelle et al, 2005
Arthroscopic labral debridement:
Short term relief
Not recommended alone
Anterolateral cartilage damage
Kain et al, 2011
What is PAO?
Augmentation and reorientation of the acetabulum to improve femoral
head coverage
Most commonly used is Bernese PAO, 1983
Polygon-shaped Acetabular Osteotomy
Encompasses ischium, pubis, and iliac portions of the pelvis
Freed osteotomized acetabulum is reoriented in desired position and
fixated with cortical screws.
Restores lateral and anterior center edge angles
Pogliacomi et al, 2005
Purpose of PAO Procedure
Normalize osseous
anatomy
Improve hip biomechanics
Decrease articular surface
overload
Relieve impingement
Decrease risk of premature
secondary OA
Clohisy et al, 2005
Additional Procedures &
Complications
In addition to the PAO, patients may also undergo:
Cam resection
Proximal femoral osteotomy
Labral repair or debridement
Complications
Transitory lateral femoral cutaneous nerve palsy
Malpositioning
Nonunion
Sciatic nerve lesion
Necrosis of acetabular fragment
HO
Benefits of PAO
Abductor, hip flexor & ER sparing
Preserves the posterior column
Enables multiplanar corrections
Preserves acetabular blood supply
Reliable healing
Preserves true pelvis
Accelerated rehabilitation
Delays need for THA
Clohisy et al, 2005; Pogliacomi et al,
2005
60% of hips survived avg of 20
years
Steppacher et al, 2008
General Guidelines
NO:
Significant AROM hip flexion – 8 weeks
SLR – 8 weeks
Simultaneous hip extension and knee flexion –
8 weeks
Driving until FWB
No pool until 3 weeks
Raise toilet seat
Avoid excessive extension and ER (legs
crossed, etc.)
Do NOT push flexion – 12 weeks
PHASE I (0-6 weeks) Home Health or HEP
Precautions:
FFWB for 20# x 6-8 weeks
PROM/AROM: 3 weeks
Flexion: ≤ 90°
CPM to 60° for ≥ 4-6 hrs/day
for 2-4 weeks
Extension: 0-5°
IR/ER: 0-20°
Abduction: 0-45°
Ice:
Day: 0-7 – All day
7+ – 2-3x/day
PHASE I (0-6 weeks) Cont. Home Health or HEP
Exercises:
Quad and glute sets
Isometrics
Ankle pumps
LAQ
Standing HS curl
Heel slides to 90°
AROM all directions*
Upright bike (3 weeks)
Standing hip abduction (4
weeks)
Stretches:
Non-operative knee to chest
stretch
Long sit HS
Prone knee flexion
Progressive “belly” time
Manual: Grade I to II
mobilizations
AP glide
Long axis distraction
Phase I: Criteria for Progression
to Phase II
Low to no pain with ADL’s (≤4/10)
Pain/pinch free ROM:
PROM flexion: > 100°
PROM abd: > 40°
AROM extension: > 5°
Quadruped rock: > 110°
Muscle strength: Pain free up to 60 reps
Prone extension
LAQ
Standing knee flexion
Posterior pelvic tilt
Prone glute set
PHASE II (6-8 weeks)
Physical Therapy
Precautions:
PROM/AROM:
Within comfort level
No IR in flexion
WBAT
Avoid twisting
PHASE II (6-8 weeks) Cont.
Exercises:
Standing hip abduction +
resistance (8 weeks)
Quadruped rocking
Bent knee fall out
Plank progression
Clams/Sidelying abd
Child’s pose
Cat/camel
Core strengthening
Short lever extension
Prone IR/ER isometrics
Stretching:
All LE flexibility exercises
Manual:
+ Scar
massage/desensitization
Phase II: Criteria for
Progression to Phase III Low to no pain with ADL’s (≤3/10)
Pain/pinch free ROM:
PROM flexion: > 115°
PROM abd: > 45°
WFL:
ER, extension, quadruped rock
Muscle strength: Pain free
Prone extension
Prone IR/ER
LAQ
Standing knee flexion
Standing march to 90°
Sidelying abd
Functional tasks:
SL balance for 60”
Ellip x 5’
Bike x 20’
PHASE III (8-12 weeks)
Precautions:
ROM:
Avoid extremes of ROM in all
directions
No forced rotation
WB:
Progress off crutches as
tolerated
PHASE III (8-12 weeks) Cont.
Exercises:
Hip rotation
Stand/sit resisted ER
Stool
Backwards and side stepping
Prone IR/ER
Bridge progression
Core roll outs
Squats/leg press to 45°
¼ Lunges
Step ups
Heel taps
Standing trunk rotation
Standing trunk rotation
Proprioception training
Advanced bridging
Cable column hip strengthening
Stretching:
Knee to chest stretch
Prone quad stretch
Manual: Grade III mobilizations
Inferior, lateral distraction, long axis
traction, AP
STM: TFL, Psoas
PHASE IV (12-20 weeks)
Precautions: Avoid forceful ROM, not too deep with TherEx
Exercises:
Dynamic balance drills
Hip strengthening is main focus
Lunge matrix
Tri-planar movements
Agility drills
Sport specific drills/plyos
Gradual hip flexor strengthening
Manual: Higher grade mobilizations
Cont. STM
PHASE V (>20 weeks) Criteria: Return to Sport/Running
Full pain free ROM
Strength testing > 90% of uninvolved side
Cardio respiratory fitness at pre-injury
level
Completion of sport specific loading and
functional training program
Progress:
Bilateral unilateral multiplanar
Acceleration/deceleration
Sagittal frontal
Tippet, 2006
References
Clohisy JC, Keeney JA, Schoenecker PL. Preliminary assessment and treatment
guidelines for hip disorders in young adults. Clinical Orthopaedics and Related
Research. 2005;444:168-179.
Kain MSH, Novais EN, Vallim C, Millis MB, Kim YJ. Periacetabular osteotomy after
failed hip arthroscopy for labral tears in patients with acetabular dysplasia. J Bone
Joint Surg Am. 2011;93(2):57-61.
McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The role of labral lesions to
development of early degenerative hip disease. Clinical Orthopaedics and Related
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Mansour A, Juneau C. Hip PAO protocol phase I handout. 2018;1-12.
Mansour A, Juneau C. Hip PAO protocol phase II handout. 2018;1-5.
Mechlenburg I, Kold S, Rømer L, Søballe K. Safe fixation with two acetabular screws
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Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of
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Peelle MW, Della Roca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and
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References
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Steppacher SD, Lerch TD, Gharanizadeh K, Liechti EF, Werlen SF, Puls M, Tannast M,
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Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese
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Sucato DJ, Tulchin K, Shrader MW, DeLaRocha A, Gist T, Sheu G. Gait, hip strength and
functional outcomes after a Ganz periacetabular osteotomy for adolescent hip
dysplasia. J Pediatr Orthop. 2010;30(4):344-350.
Tippet SR. Returning to sports after periacetabular osteotomy for developmental
dysplasia of the hip. North American Journal of Sports Physical Therapy. 2006;1(1):32-
39.
Wells JE. Periacetabular osteotomy protocol handout. 2018;1-3.
Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur
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