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CARE AFTER SURGERY
You or your loved one’s surgery will result in some degree of pain, but your doctor and health care team will work to keep you as comfortable as possible. Factors such as age, smoking status, nutrition status and mobility levels can influence healing. Your doctor will discuss with you the time frames for your or your loved one’s healing after the surgical procedure is complete.
UNDERSTANDING LIMB CORRECTION
Bone deformities are surgically treated by bone correction or bone lengthening procedures. The surgeon creates a cut across the affected bone, prepares it to receive the orthopedic device and then places the device that will aid with your bone correction. This procedure is called osteotomy and may be performed with either internal or external fixation devices to stabilize the target bone.
Limb deformity correction devices that remain outside of the body are called “external fixator devices;” whereas those that are inserted into the bone or directly over the bone are called “internal fixator devices.”
The process of slowly separating and straightening the bone segments is called distraction, which means “to pull apart.” The distraction process helps create a space that allows for new bone to grow in between, thus straightening the affected bone. In this phase, your orthopedic surgeon can also correct angular deformities with some type of external fixators.
During the distraction phase, the patient or care giver may be asked to adjust the orthopedic device every day to correct the deformity. The patient will be also asked to see the doctor at scheduled time periods and have additional X-rays to make sure the bone correction proceeds as planned. Also, it is during this phase that the patient will be asked to attend physical therapy sessions as instructed by the surgeon.
Following the distraction phase is the consolidation phase, where the new bone starts to harden. The bone is healed when the new bone has completely hardened and calcified. The consolidation phase takes approximately twice as long as the distraction phase. For example, if distraction is completed in 1 month, then consolidation will take 2 months. You may be asked to gradually apply more weight to the affected area, which encourages new bone growth.
What Could Prevent a Bone Deformity from Being Corrected?
If you do not follow your doctor’s instruction or avoid physical therapy, your muscle strength and range of motion could be affected. Resulting muscle contracture or nerve problems can force the doctor to stop the deformity correction process.
LIVING WITH YOUR ORTHOPEDIC DEVICE
Preventing Accidents
During your post-operative stay at the hospital, it is important to follow the instructions that shall be provided to you by your doctor and health care team. Serious falls occur when patients try to be independent too soon and do not ask for help in a timely manner. Keep the following information in mind post operatively both at the hospital and at home after discharge.
At Discharge
You should be provided instructions by your health care team prior to leaving. You may ask them to provide all instructions in writing. Your post-surgery list of the medications should also be explained in detail. Feel free to ask questions if you do not understand your medication regimen or any instruction. Other practical pointers include:
What you will need for your trip home: this will include the loose-fitting clothing, proper, non-skid shoes, etc. These items can be brought in by a family member on the day of discharge.
Pain Relief
You or your loved one may experience some discomfort after leaving the hospital. This is normal, and likely due to being more active at home than in the hospital. Pain will decrease over a few weeks. In the meantime, you/your loved one can take the painkillers that have been prescribed, according to need and instructions. If pain increases acutely or does not go away as expected, contact your surgeon or family doctor. As the pain decreases, you can eventually stop taking the painkillers.
Exercises and Physical Therapy
Exercises will be taught to you/your loved one by a physical therapist at a specified time decided by your doctor post-surgery. Other than you, your caregiver may also be taught these exercises, to assist you in performing them.
Physical therapy exercises should be performed according to the instructions of your physical therapist. Performing them at the rate specified will help strengthen the muscles, joints and bones by preventing joint stiffness. It is crucial to do these exercises, but don’t overdo these exercises. Please perform the exercises per your therapist’s instruction.
The gradual pressure applied by your body’s weight on the healing bone(s) through your skeleton and muscles, during which the fixator device safely holds the healing limb, is one of the reasons external fixation treatment is successful. This weight bearing assists with the healing process and your physical therapist will help teach you/your loved one how to gradually bear weight on the healing limb. Following physical therapy instructions is extremely important to making sure you/your loved one gain the maximum benefits of surgery. Bear in mind that excessive exercise may also be harmful. Always follow the physical therapist’s instructions.
The target areas for physical therapy after surgery include:
Strength: strengthening the muscles that support your affected limb facilitates its healing. Keeping these muscles strong can help prevent further injury.
Flexibility: stretching the muscles is important for restoring range of motion and preventing injury.
POST-SURGERY CARE
This section details the care instructions for external and internal fixation surgical treatments, one of which you or your loved one may be scheduled to receive.
External Fixation Post-Surgery Care
This section relates to limb lengthening or correction surgeries using external fixator devices such as the circular or monolateral devices (for more info on types of external fixators look here).
After the surgery, you should not put any weight on your operated leg until further instruction from your surgeon. The surgeon may also inform you about not allowing your incisions to get wet in the shower or bathtub until a certain level of healing has taken place. The proper method to bathe and protect the surgical site area should be taught to you prior to discharge.
It is also important to know that even after significant healing has occurred, your surgeon may ask you to keep the external fixator on for a certain number of months. During this phase, you may be allowed to take more normal showers and wetting of the surgical site shall be allowed again. However, maintenance of the device and pin site should be continued until the external fixator is completely removed.
Your surgeon will give you information on potential post-operative complications (such as pin-site infection, joint stiffness or muscle contractures, and wire or pin breakage), and the signs that you should seek treatment, as well as the appropriate health care professional to contact.
In your first post-operative visit, your surgeon will check your incisions and take X-rays of your limb. You will be trained to put limited weight on the operated limb and shown how to manipulate it. By varying activity levels, you should be able to control the rate of lengthening accurately to that prescribed by your surgeon. In some cases, the assistance of a family member or other individual may be necessary to accomplish the required exercises.
You/your loved one will be taught how to clean the pin sites – that is, the area of skin around the pin or wire, where it passes through the skin. Follow exactly the instructions for pin-site care in the brochure and/or video provided by your surgeon or hospital staff after surgery.
The care following an external fixator device surgery involves also the fixator device itself. You can clean the fixator frame with a damp cloth or cotton swabs to keep the whole fixator free of dust, grease or dirt. Once a certain level of healing has taken place, you will be permitted by your doctor to wet the surgical site during a shower. You may clean the fixator gently with soap and water, drying it afterwards with a clean towel. If you/your loved one has taken a bath, rinse the frame and pin sites with the shower head afterwards and use a sterile cleansing solution as instructed by your health care team.
All pin sites need to be checked every day. If the pin site becomes “clogged” from leakage that has dried, the site will need to be cleaned as instructed by your doctor/heath care team.
If you have been treated with a circular external fixator that requires adjustment, your surgeon will explain the schedule and how many visits will be needed. Adjustments to the external fixator will begin between 5 and 14 days after your/your loved one’s surgery, starting sooner in younger patients.
You will be shown by your surgeon how to adjust the length of your fixator frame along with the number of times a day you need to do this.
This allows lengthening of your bone at a comfortable rate, letting your new bone grow in the surgically created space. Lengthening too fast may mean that new bone cannot grow fast enough and this will cause problems with bone healing. Lengthening too slowly may result in the bone growing together before lengthening is done.
By taking regular X-rays or ultrasound pictures of your bones, your doctor will ensure that the adjustments aren’t happening either too fast or too slowly and may ask you to change the rate of adjustments as a result. Even when your leg reaches the right length and angle, you/your loved one will still wear the fixator as the bone gains strength. Once the bone has reached a certain level of healing, your doctor will remove the external fixator device and you may need to wear a cast for a short while after the fixator frame has been removed.
Internal Fixation Post-Surgery Care
Internal fixation is when the device is used to lengthen the bone from inside the bone. After insertion, the patient will stay in the hospital for about 2 to 3 days.
Physical therapy is crucial as it allows for the muscles, tendons and ligaments to be stretched in order to ensure that the arm or leg will have full movement after treatment. Patients will need physical therapy if they are lengthening the bones in the legs or occupational therapy if they are lengthening the humerus (upper arm bone).
The patient will be allowed only limited weight bearing on the affected limb. The doctor will determine how much weight bearing is allowed and the size and type of the nail that is implanted. If both legs are to be lengthened, a wheelchair would be required for the post-surgery healing phase.
Some pain and swelling are expected post-surgery. Your doctor will prescribe pain killers and other medication to help make the post-operative phase as comfortable as possible.
The following are some guidelines to keep in mind post internal fixation surgery.
You may have a tape placed on the site of incision. This is to be kept in place until the doctor allows you to remove it or until it naturally falls off. When your doctor allows you to remove the bandage, you may clean the incision site per your doctor’s instructions.
You might be asked to prop up the injured arm or leg on a pillow as you ice it or anytime you sit or lie down during the first 1 to 2 weeks after your surgery.
If you have a cast or splint, it is advisable to:
Be sure to make and go to all appointments and call your doctor or nurse call line if you are having problems.
Implantation of a guided growth plate is performed under anesthesia and takes about an hour. During the procedure, the surgeon will make a 2-3cm (approximately 1”) incision at the physis of the bone to correct. The plate is secured to the bone with two small screws. The incision is closed, generally with resorbable sutures. After recovery from anesthesia, your child may be taken home. This technique involves minimal surgical trauma and pain when compared to an osteotomy. Although your surgeon will provide details on your child’s specific case, a cast is generally not required and crutches are usually optional (for comfort). Subject to your surgeon’s medical judgment, typically children are encouraged within three weeks from the surgery date to walk and resume activities as tolerated.
The guided growth plate temporarily restrains growth on one side of the bone plate while natural growth is allowed to continue on the opposite side. Gradually over time, (typically from several months up to one year) the deformity is corrected. To ensure timely and adequate correction, your child needs to be seen by the surgeon every three months for a check-up or as recommended by your surgeon. When the deformity is corrected, the surgeon will remove the guided growth plate under anesthesia in an outpatient surgery.
If you have been treated with a lengthening nail, your surgeon will explain the schedule and how many visits will be needed.
A load of up to 20 kg on the affected leg is typically permitted. Stacked shoes are used to compensate for differences in leg length. Physical therapy is initially limited to the prevention of pulmonary and thromboembolic complications. Exercising of the knee joint typically starts from the fourth post-operative day. Always follow the physical therapist’s instructions.
The distraction phase will typically start 5 days after your/your loved one’s surgery. Your surgeon will give you a special device and you will be shown how to use it to activate the motor inside the nail. This will allow the lengthening of the nail and of your bone.
You may need to repeat this action several times a day to reach the planned bone lengthening as prescribed by your surgeon. This allows lengthening of your bone at a comfortable rate, letting your new bone grow in the surgically created space. Lengthening too fast may mean that new bone cannot grow fast enough and this will cause problems with bone healing. Lengthening too slowly may result in the bone growing together before lengthening is done.
By taking regular X-rays of your bones, your doctor will ensure that the lengthening isn’t happening either too fast or too slowly. Your doctor may ask you to change the rate of corrections as a result.
When the distraction is complete and the correct leg length is attained, the soft regenerate begins to calcify into hard bone. Your surgeon will use X-ray pictures of your limb to determine when your bone has hardened enough to allow you to place all your weight on your leg again. After that time, you may choose to have the device removed from your leg with another surgical procedure.
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