Tuesday, June 11, 2013

 (Most pictures taken while Robbie's in his wheelchair as that's his 24/7 location)
Twist very noticeable as is the bruise from the pressure area on the right lower back due to the pressure of being pushed against the back cushion.

Black marker as guide. Hardly any twist. Pressure sore has healed with no bruising presently. Also sores under the right upper thigh have totally healed. Skin all good in tendon release area, butt and back.
By observing the chest and knees from above the twist is also very clear
Considerable change of knee alignment.

Legs parted by straps but not causing as much groin area pain as pre-op which limited the amount and time of strapping. Feet almost level due to post operative strapping holding down his left knee that rises and travels to the left due to shortened Iliofemoral ligament and abductor contracture. 
Now to discuss with orthopaedic surgeons possible partial tendon release of abductor muscles and partial Iliofemoral ligament release to help reduce contracture range that force Robbie's knees toward his chest when horizontal as shown below.
Due to shortened nerves and blood vessels in the Iliofermoral area due to Robbie's legs never having experienced total straightening there has been some concern from a surgeon of the legs dropping and causing more pain as the Femoral nerve and blood vessels are stretched. But since Robbie sits 24/7 the legs will not be dropping. The only time his upper legs would be subject to extension or 'dropping' after any partial tendon or ligament release would be during gentle physiotherapy on the floor or bed. Over a long period of time and appropriate physiotherapy the nerves and blood vessels would stretch to a lesser or greater degree. Robbie's own mobility expectations would not subject him to long periods of unbearable pain that would only make him more tense and have a detrimental effect on his progress forward. He and I are rational about what can and can't be achieved due to any possible anatomical limitations that could be totally or mostly irreversible and that have been caused through 40 years of living with cerebral palsy that was not appropriately addressed as a child.
The partial tendon release performed on the 4th of June helped separate his legs to improve access to his groin area and reduce his penis being crushed. But the problematic Iliofermoral ligaments hinder access to the creases between his torso and top legs and cause incredible pain when strapping his legs down and tilting him back to reach this area for cleaning. The tight top tendons of the abductor muscles naturally make access to his colostomy - that is directly above his right leg - very difficult and contractures have often compromised it by crushing and causing leakage.
Also, the extent of Robbie's osteoarthritis must be clarified in order to conclude how much this is limiting the flexing of his hip joints, if any. Could the problem be solely a very shortened and tight Iliofemoral ligament that has become so tight that even under anaesthesia it's not possible to straighten his hip joints.


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