Training Children With Van Nes Osteotomies

C. Killips, R.P.T.


Cases 1 (S.N.) and 2 (D.N.), which were discussed in Dr. Hall's article (page 3), received their training and prosthetic fitting at the Ontario Crippled Children's Centre following their tibial-rotation osteotomy. Each child had worn a prosthesis prior to the surgery.

General Training Procedures

  1. A tensor bandage was applied after the plaster cast was removed. It was worn all day and throughout the night until the swelling in the limb had subsided

  2. Exercises to maintain and improve the range of motion in the ankle joint (new knee joint) and to strengthen all muscle groups of the hypoplastic limb were performed with the anatomical knee joint in the extended position.

  3. A progression of exercise, leading to the coordination of one leg with the other, was followed.

  4. Weight-bearing on the hypoplastic limb was encouraged to increase tolerance.

  5. Frequent handling of the hypoplastic limb was employed to promote acceptance, to eliminate apprehension toward handling, and to reduce the sensitivity of the limb prior to fitting.

Aspects of the preprosthetic and prosthetic programs are described below for the two cases.

Condition of Limb After Plaster Was Removed

Case 1 (S.N.) -10-Year-01d-Girl

  1. Sensation good.

  2. Considerable swelling of the foot at the time of admission. In approximately 2 1/2 weeks, this swelling had decreased sufficiently to take the cast for the prosthesis.

  3. Pain on full dorsiflexion of the stump.

  4. Limited range of dorsiflexion (lacked about 40 degrees).

Case 2-3 1/2-Year-Old-Boy

  1. Sensation good.

  2. Minimal swelling-no problem with cast-taking for the prosthesis.

  3. No pain from pressure on the stump or through the range of motion.

  4. Full range of motion in plantar-and dorsiflexion.

Active Range of Ankle (New Knee)

Case 1 (S.N.) -10-Year-01d-Girl

  1. A full range of active plantar flexion was obtained within a few days.

  2. Ninety degrees of dorsiflexion was present within two weeks after removal of the plaster cast. A full range of dorsiflexion was obtained in three weeks.

  3. Knee extension was just short of 180 degrees; knee flexion was about 80 degrees.

Case 2-3 1/2-Year-Old-Boy

  1. A full range of active plantar and dorsiflexion was obtained within a few days.

  2. Knee extension was just short of 180 degrees; knee flexion was approximately 80 degrees.

Exercise

(Active and resistive exercise to strengthen the ankle joint (new knee joint), coordination of knee flexion-extension, bilateral and reciprocal movement of the two lower extremities, and hydrotherapy.)

Case 1 (S.N.) -10-Year-01d-Girl

  1. Adjusted quickly to program.

  2. Initially was able to take some resistance through the partial range of plantar and dorsiflexion.

  3. Initially was able to perform active plantar flexion through the full range, and dorsiflexion through a partial range.

  4. Coordination of knee flexion and extension improved and was quite good after four weeks of training.

  5. Very good strength of knee flexion and extension obtained in approximately eight months.

Case 2-3 1/2-Year-Old-Boy

  1. Required approximately 2 1/2 weeks to adjust to the Centre and the staff.

  2. Tolerated resistance to plantar flexion quite well after adjustment to therapy.

  3. In play activities could actively operate through full range of motion.

  4. Good coordination of flexion-extension achieved in two months.

  5. Very good strength of new knee flexion and extension obtained in eight months.

Prosthetic Fitting

Case 1 (S.N.) -10-Year-01d-Girl

  1. Was performed approximately one month after admission, by which time the swelling had been sufficiently reduced.

Case 2-3 1/2-Year-Old-Boy

  1. Was performed just over one month after admission. Cast taking was delayed for a few days longer than physically necessary because of patient's apprehension.

Prosthetic Gait Training

Case 1 (S.N.) -10-Year-01d-Girl

  1. Walked with crutches and applied minimal weight through the prosthesis for the first few days. Took a few steps without crutches after two weeks. Used elbow crutches to ambulate long distances. Walked independently and managed stairs and ramp after three weeks. Had achieved good control of prosthetic knee flexion and extension and a good gait eight months after receipt of the prosthesis. Some lateral body sway was observed during walking.

  2. Total follow-up has been approximately ten months and three weeks.

Case 2-3 1/2-Year-Old-Boy

  1. Walked independently with knee flexion and extension in one week (illness in the middle of this period delayed training). Good control of prosthetic knee flexion and extension was achieved 3 1/2 months after receipt of the prosthesis. A good gait was also attained by this time, but a tendency toward internal rotation of the prosthesis was noted.

  2. Total follow-up of training has been approximately ten months.

C. Killips, R.P.T. is associated with the Physio-Therapy Department Ontario Crippled Children's Centre Toronto, Ontari