Rehabilitation Guidelines after Periacetabular Osteotomy (PAO)

Transcription

1 Rehabilitation Guidelines after Periacetabular Osteotomy (PAO) March 2017 Bobby Jean Lee, PT, DPT, SCS, CSOMT, CSCS, USAW Texas Health Sports Medicine Fort Worth, TX

2 Objectives 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

3 HIP PRESERVATION

4 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

5 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

6 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

7 Imaging Indications A/P and Lateral Rx Views: Pelvis Increased acetabular retroversion (cross over sign) Normal = of anteversion Acetabular protrusion Measurements: Tonnis angle (AI): Normal < 10 Abnormal 15 Center edge angle of Wiberg: Normal > 25 Dysplasia < 15 Nunley et al Mechlenburg et al. 2007

8 Steppacher et al, 2014

9 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

10 PAO

11 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

12 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

13 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

14 Benefits of PAO Abductor, hip flexor & ER sparing Preserves the posterior column Enables multiplanar corrections Preserves acetabular blood supply Reliable healing Accelerated rehabilitation Delays need for THA Clohisy et al, 2005; Pogliacomi et al, % of hips survived avg of 20 years Steppacher et al, 2008 Preserves true pelvis

15 PROTOCOLS

16 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

17 PHASE I (0-6 weeks) Home Health or HEP Precautions: FFWB for 20# x 6-8 weeks PROM/AROM: 3 weeks Ice: Flexion: 90 CPM to 60 for 4-6 hrs/day for 2-4 weeks Extension: 0-5 IR/ER: 0-20 Abduction: 0-45 Day: 0-7 All day x/day

18 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

19 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

20 PHASE II (6-8 weeks) Physical Therapy Precautions: PROM/AROM: Within comfort level No IR in flexion WBAT Avoid twisting

21 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

22 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 Functional tasks: SL balance for 60 Ellip x 5 Bike x 20 Muscle strength: Pain free Prone extension Prone IR/ER LAQ Standing knee flexion Standing march to 90 Sidelying abd

23 PHASE III (8-12 weeks) Precautions: ROM: Avoid extremes of ROM in all directions No forced rotation WB: Progress off crutches as tolerated

24 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

25 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

26 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

27 + THANK YOU!

28 + QUESTIONS??

29 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: 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): 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 Research. 2001;393: 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 after Ganz periacetabular osteotomy. Acta orthopaedica.2007;78: Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone joint Surg Am. 2011;93(2): Peelle MW, Della Roca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clinical Orthopaedics and Related Research. 2005;444:

30 References Pogliacomi F, Stark A, Wallensten R. Periacetabular Osteotomy. Acta Orthopaedica. 2005;76(1): Steppacher SD, Lerch TD, Gharanizadeh K, Liechti EF, Werlen SF, Puls M, Tannast M, Siebenrock KA. Size and shape of the lunate surface in different types of pincer impingement: theoretical implications for surgical therapy. Osteoarthritis and Cartilage. 2014;22(7): Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Rela Res. 2008;466: 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): Tippet SR. Returning to sports after periacetabular osteotomy for developmental dysplasia of the hip. North American Journal of Sports Physical Therapy. 2006;1(1): Wells JE. Periacetabular osteotomy protocol handout. 2018;1-3. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in absence of bony abnormalities. Clinical Orthopaedics and Related Research. 2004;426: