Pediatric dwarfism clinic
(Chung-Buk Rehabilitation Center,rehabilitation specialist)
Management of necrosis and decubitus (bedsore)
2~3 weeks after the surgery, disinfection was done around the operated area, but after that, disinfection was done mainly for necrosis or bedsore. The necrotic area was located on the operated areas in Soo-Jeong’s both feet and Sang-Il’s one foot. In my opinion, I think the thin soft tissue of the foot was more prone for necrosis compared to the thick soft tissue in the thigh. At first we were waiting for its natural recovery through disinfection, but we performed debridement after we saw no improvement.It took about 6 weeks to 3 months for the necrotic tissue to fully recover.
However, decubitus was seen in Yu-Bin’s both heels and Hye-Ji’s one foot. Decubitus usually occurs because of the pressure caused by the splint put on after the surgery. I think the family members at our center were less responsive to the bedsore because of their mental status. The decubitus areas didn’t resolve natural either, so we ended up having debridement in those areas as well. From that point on, it took about 2 weeks to 7 months for complete recovery.
Management of the Ilizarov device
The most troublesome and memorable incident had to do with Sang-Il’s Ilizarov device. Because it was also my first time dealing with the device, I learned how to take care of it once from the doctor in charge at the ward, and then once again from the outpatient cast room. Each time I disinfected the skin around pin insertion twice every day, I turned the screw 0.25mm each time, lengthening 0.5mm in total every day. This process could seem very redundant and boring, but it was definitely not something that could be neglected. So despite the busy schedule, disinfection and Ilizarov lengthening was always done by me and a church sister who used to work as a nurse.
Once a week, we went to a nearby hospital to take x-rays around the area with the Ilizarov device and sent those files to KUMC. His device was lengthened 10.25mm every day for 3 weeks, then 3.25mm for a week, and lastly, 7mm each day.
We kept the same rate for quite a while, but ended up noticing flare, edema, pus, and heated inflammation around the pin insertion site. So we tried icing the area to cool down the area. Fortunately, he started showing improvement the next day and resolved eventually.
He was able to have the Ilizarov device about 9 weeks after the surgery, which was earlier than expected. I personally thought we could have lengthened it a little longer. But it was certain that the leg length discrepancy that had been reduced compared to his pre-surgical status. But I think Professor Song was concerned about the disadvantage of elongation of the process that he decided to stop lengthening after a reasonable amount.
Putting on orthosis
Hye-Ji and Yoo-Bin, who received surgeries only for the soft tissue, had their splint removed 2 weeks after the surgery and changed it to Hip-Knee-Ankle-Foot-Orthosis (HKAFO), which they had on for about 3 months. Soo-Jeong, who had the surgery for the bones of her foot, got a cast at her first outpatient appointment and put on HKAFO after 7 weeks. After that she wore Ankle-Foot-Orthosis (AFO) which we assembled at our medical clinic for 4 months and is using special insoles to support the arch of her feet. Sang-Il, who received the Ilizarov limb lengthening surgery, had his cast removed at his 2nd outpatient appointment. He got the cast removed at his 3rd outpatient visit and used HKAFO for about 4 months starting from the 3rd week of surgery. Currently, he is using orthopedic shoes that were made to balance the lengths of his legs.
All four patients went through one procedure in common, which was hip adductor release. So there was a pelvic belt attached in all the HKAFOs they got. But when I treat patients, I usually try to recommend orthosis that are comfortable for usage throughout daily life, rather than big and burdensome devices.
Generally, as the AFO gets bigger, it becomes harder to suit well on the patient’s body. Not only it is hard to put on, but it also seems unnatural when the patient tries to move. On the other hand, bulkyorthoses are better as far as safety, support, and protection are concerned. So I wonder if it would be better to call these rather burdensome devices “protection orthoses”. But I think these bulky ortheses are commonly used at orthopedics because their main focus is safety and protection of the operated area. But I think if there were devices that were more simplified with the same protection and safety functions,it would increase the usage of the device by the patients, which would be helpful for early rehabilitation treatments.
When we first got the orthosis during outpatient, I wish we could have got simple adjustments such as heel cutting and adjusting the foot length done at the hospital. If this adjustment was done at the hospital, patients wouldn’t have to go out of their way to individually visit the manufacturer.
Rehabilitation treatments at Chungbuk Medical Center
Our family members were started with rehabilitation therapies under my supervision. At first, the patients were still in the “self-support” room, getting therapy around their beds. Initially, the knee joint was locked on the orthosis so that the patients could practice standing, while holding on to the bed rails. When they got used to the standing position, we unlocked the knee joint so that they could bend. The next step was to stand without holding onto anything. At this point, the patient was moved from the “self-support” room to the rehabilitation center, where proper rehabilitation program was started. The family members also returned to their own usual places in their rooms. They began their physiotherapy with walking by holding onto a walker or the physiotherapist’s hand. As they practiced walking, their concentration and sense of balance improved and they were able to walk by themselves with the orthosis on. After this, they started to train walking outside the physical therapy room. They practiced walking up and down the stairs while holding onto the rails or with the help of the physical therapist. Eventually, they were able to walk by themselves without anyone’s help. After stepwise training, we went to KUMC for orthosis removal, then the family members were trained again without them.
All the family members who were operated basically followed the training program explained above. The effectiveness or the progress rate was different for every family member. The major factor affecting this was the level of disability (ability of movement) before the surgery. For example, the member who had walking disability was late with functional recovery as well. The second factor was the area of surgery in the body. The patients who had surgery only one leg had faster recovery than the patients who had surgery on both legs. Also, patients who only had surgery in the soft tissue such as muscle and tendons had faster recovery than those who had additional bone surgeries. The third factor was cognitive function. The better patient’s cognitive function was, the more participating and cooperating the patient was for the therapies, whereas worse cognitive function was accompanied with less cooperation and slower recovery.
With the training mentioned above, we also gradually carried out strengthening and PROM, stretching exercises as time passed. Strengthening and stretching exercises were especially important for Sang-Il, who had received the Ilizarov surgery. Because the surgery involved lengthening of the tibia, we were particularly cautious during strengthening isometric exercise to prevent any kind of complications or refracture. He did more of stretching exercises after his casts were removed from his both legs.
It was very delightful to see our members regain their exercise functions through various rehabilitation therapies. I think the recovery was fast thanks to the care and encouragement from me, the physical therapist, and all the employees of Chungbuk Rehabilitation Center. Currently, our family members are receiving regular rehabilitation therapies to maintain the corrected status and to avoid postsurgical deformities.
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