Are Wheelchairs Hurting Children’s Hips? | S2 EP1 with Dr. Mathias Axt ( Pediatric Orthopaedic Surgeon)

We are back for Season 2 — and we are kicking things off in a big way.

I'll be honest with you. Hip abduction in non-ambulant children is one of those topics that every clinician I know has wrestled with at some point. How much abduction is enough? Are we helping or are we making things worse? Should every non-ambulant child be sitting in abduction? And what on earth do we do with a windswept deformity?

I've been hearing Dr. Mathias Axt's name out in the traps for years whenever these questions come up — and now I finally got him on the pod. Dr. Axt is a pediatric orthopedic surgeon with over 20 years of experience in children's hospitals, specialising in hip development, surgical management, and long-term outcomes in non-ambulant children. The man knows his stuff, and he does not hold back.

This episode is for you whether you're a clinician, a wheelchair rep, or a parent or end user trying to make sense of what you've been told about seating and hips. We cut through the confusion and get into the real clinical principles that should be driving these decisions.

In this episode, we cover:

• Why hips migrate in children with cerebral palsy — and why they're normal at birth
• The role of muscle imbalance, Coxa Valga, and antetorsion in hip displacement
• Why abduction is a tool, not a rule — and what the 20-degree principle actually means
• The danger of forcefully abducting an already subluxed hip
• Windswept deformity — what it is, why it matters, and how to seat around it
• Why frog leg positioning is something we want to avoid and what to do instead
• The problem with standard contoured cushions and why flat cushions with adjustable pommels may serve these kids better
• Why pelvis rotation is more important than leg symmetry
• The call for better collaboration between clinicians, wheelchair reps, and manufacturers

This one genuinely changed the way I'm thinking about how we seat these kids. Subscribe, leave us a review, and share this with every clinician and wheelchair rep you know because this conversation needs to keep going.

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Disclaimer: The views and opinions expressed in this podcast are solely those of Anthony and Justin.

Transcript

SPEAKER_00 0:00

If you forcefully attack the hip, you actually make the whole situation much worse. Because even if someone looks wrong, they might be wrong. I think it's what is very important. I don't want external rotation. I don't want the knees out and the feet in at the narrow footprest. One of the biggest factors of migration to subscribe is muscle imbalance and muscle weakness. So all muscles are weak. I think the number one thing that we want to prevent.

SPEAKER_01 0:40

Hello and welcome to WheelChat. We are back, and we are back big. Anton, who do we have? Oh well, I'll tell you something. We are kicking things off massive this week because we're we're back, we're excited. This topic, I would say, is pretty much every clinician's sort of working with complex seating has probably wrestled with at some point, haven't they? Hip abduction, enormous ambulant children. I guess if you've ever asked yourself how much abduction is enough, how long should we be doing this for? Are we helping or are we potentially causing harm? You are definitely not alone because we have somebody today who's been thinking deeply about this exact question for I would say over two decades from my research. Dr. Mateus Axt is a pediatric orthopedic surgeon who has spent more than 20 years working in children's hospitals, focusing on hip development, surgical management, and long-term outcomes in non-ambulant children. No one better, genuinely, to ask the questions to. And really, what we're excited about is the experience that you're going to bring. Dr. Axed, welcome to WheelChat. We're excited to have you on. Good morning. Thank you, Anton.

SPEAKER_02 1:57

Good evening over here. Firstly, before we even kick anything off, Doctor, I just want to say I heard your name years ago just coming around, and I thought it was the coolest name for an orthopedic surgeon. When I thought your name was Dr. Axe, like A X-E. I thought, what a cool name. Someone going around calling himself Dr. Axe, who's like cutting up the cutting up people in surgery. And then I realized your name is actually, is it a German name? Yes, it is a German name.

SPEAKER_00 2:20

Axt with a T, but it means Axe. It's the same. Oh, there you go. It's basically the translation of Axe in into German, yes, it's fine.

SPEAKER_02 2:31

I really wanted to come bring you on to you today because, like I said, I've heard your name uh out in the traps over the years. Specifically when I have to seat a child in a wheelchair, and I'm being told I have to sit the child with almost like 45 degrees of leg abduction. And it's inconsistent from what I've heard. Sometimes I hear it's they need to be sitting in this way for years, sometimes it's just, you know, for the next few months. And I'm not really sure, it seems like no one's really sure what the guidance is, but your name always pops up. So I thought it's a great person to ask. Question I want to ask is, and I want to get everyone who's listening today, if you are working with children, who are the children that need to sit in abduction? For those who don't know, abduction is when our knees go out to the side. Who are the people that need to sit in abduction and why are we doing it?

SPEAKER_00 3:16

Good question. How much abduction do you need? Well, and I can only say it depends very much whether the patient has low tone or has high tone. And I can only say, regardless what where the hip actually sits, and I can explain why hips sublux and dislocate in children with cyber palsy, but in children with high tone and high spasticity, where you barely can separate the legs, you cannot sit those children or place them into a deduction because it will actually harm the hips. It will cause only stress, more stretch to those already spastic and tight muscles, and potentially pain and potentially too much pressure in the hip joint, you know. So I have to do something to those hips first before you can allow them to sit in more hip abduction. And also, if a child has abundant range of motion, then it is actually not so important to have a lot of abduction, only a little bit of abduction is important. Why is that so? So, first of all, the hips in a child with cerebropausy, we're talking about cerebrosy, these are normal at birth. So completely normal. And then over time they displace and migrate outwards, out of the socket. But where do they actually migrate into and why? So, first of all, muscle imbalance, so one of the biggest factors of hip migration in children's pose is muscle imbalance and muscle weakness. So all muscles are weak. Whether they're spastic or not, they're still weak. But there are muscles weaker than other muscles. And the weaker muscles are the hip extensors and hip abiductors, those those muscles that drive the legs out and straighten the legs. These are the weak ones. And the muscles who bring the legs together, the so-called adductors and the flexors who bend the hips, they are strong. So they cause an imbalance. And therefore, they drive slowly the hips upwards firstly and then outwards. And in children, with a bossy more outwards. Okay. So if you then A B duct the hips, then you actually redirect the ball more towards the center of the hip joint. And also another important factor is that the thigh bone at the upper ends, we talk about the neck and the shaft, is differently configured to a normal child. So we have a steeper angle between the neck ends and the shaft. It's called coxavelga. And we also have more rotation. We call this intertorsion or interversion. So meaning that the neck is pointing forward. So that actually, when the child sits, really uh rubs more on the posterior rim and then helps the ochi, prevents the socket to develop properly. So when you see that the hip slowly moves out, then you see that there is as steep as a tabulum because the pressure in those children with the with the ball driving or driving up the socket is about 200 times as high as in normal children. So in Coxavelga and with high pressure, the rim cannot ossify because the cartilage cannot turn into bone because that pressure is simply too high.

SPEAKER_02 6:56

Before you continue, I just want to summarize where we're at so far because you're saying some great things. I want to clarify that I understand. So right now we're specifically talking about children with cerebral palsy, not necessarily other conditions. So in cerebral palsy, they're at normal at hip birth, but after time the hips migrate because there's a muscle imbalance and all muscles have been weakened, but some are weaker than others, and the ones that become weaker than others are often the abductors, the ones that allow your legs to go out. And so for that reason, our hips start to the ball, the ball in the socket isn't the ball isn't going in the socket as much. As well, uh, what also happens is that the neck shaft of the femur isn't developing in the right angle. So there's two things happening. There's the muscles that are pulling the joint out, or the neck angle itself is not actually forming correctly in the acetabulum. Is that the word that's the socket?

SPEAKER_00 7:45

The socket is the acetabulum. And because of the high pressure of the femoral head, the ball, pushing against the rim of the acetabulum, that cartilage, which most of that in a small child is cartilage, but the cartilage wants to ossify, wants to turn into bone. That is a natural development of the hips. And that can't happen because of that pressure. It's actually the the Hütter-Faultman law not allowing physiological pressure in that hip joint, so the bones can't develop normally. And therefore the acetabulum, so the cup, as well as the thermal head, become dysplasted. And then once that has started, uh, because there is less pressure when the thermal head points towards or into the soft tissues, into the capsule, it comes to a misshaped thermal head, it's rather square-shaped than round. And that's then if you try to put the ball back into socket, they don't really match anymore. Rampeg square hole. Yes. So the other thing is gravity. Gravity is an extremely important factor. As you know, children start not typically walking around the age of 10 and 14 months. And if that doesn't occur, then the the particular the thigh bone at the to at the upper end, like the rotation we call this torsion. So it's actually turning, turning basically, if you look at my fist, turning forward. Baby is born with 30 degrees anti torsion, and it slowly until adulthood turns back into about 10 degrees anti torsion. And also because of the lack of gravity, the neck shaft angle itself, which should be 128 degrees, is not being maintained, but it becomes steeper and steeper and steeper because the muscles should drive the bones. Form follows function basically, and the form of the proximal femur is not properly developed because of the muscles not driving the hip joints and not having concentric uh pressure within the hip joint. So there is persistent or increasing coxavulga and there's persistent anter torsion, you know, and that that's part of the picture. So both parts, the thigh bone as well as the acetabulum, don't develop normally and become more and more what we call dysplastic and don't match very, very well after some time.

SPEAKER_02 10:13

Yeah. So a lot from what you said, the muscles, all that stuff happened, I get that. Is that specific? So with the first part you said, is that a CP specific? And then the last one could be like spina bifida, like someone with spina bifida, for those who don't know, spinobifida is essentially like a spinal cord injury for a child where there's uh it's a similar effect. Do they also get these effects, or is it just the last one because they're not loading, the bone doesn't shape properly?

SPEAKER_00 10:36

So spinobifida is a little bit different because spina bifida is often born, they're often born with dislocated tips or sublux tips to start with. Cerebral positives are typically normal, but also other neuromuscular conditions, for instance, SMAs, another another big chapter. They are low-tone initially, and then over time the muscles become rigid and don't allow the range anymore. In particular, the hip adductors uh become tight and the hip abiduct. So hip adductors become tight and the hip abiducts remain the same. So the child develops an adduction contraction, and that also helps because the child is still not walking, so the joint partners can't develop, and that also helps to drive the hips out. And typically, a children with SMA have hip dislocations around the age of five, five or six, you know, but similar according to the what we call gross motor function classification system, hip displacement has a linear correlation with the severity of the disorder. Like GMS level 1s have zero, GMFC level five children have 90% of risk of hip dislocation. And and that has a big impact on those child because it's it often goes with pain and severe uh contractions at the hip joint. And the inability, for instance, to standing or to do proper sitting, you know. And on you go ahead.

SPEAKER_01 12:07

What I would like to do is really sort of move that forward and sort of understand, first of all, in terms of core principles, like what are the key principles you have developed over your well, I've said 20 plus years of experience, but many, many, many years of experience. And also, can you just expand on the idea that Justin came up with? So I'm not going to call this one Justin, this is yours, which is abduction is a tool, not a rule. Those would be a good kickoff for me.

SPEAKER_00 12:34

Okay, so what we want to have is uh the hips safe in the depth of the socket. So you can imagine if we have what we call a coxabelga, so the increase of the neck shaft angle from typically 128 degrees, we mimic with abduction, we mimic the normal neck relationship, so the ball and neck relationship in the socket. Yes, the hips are in that case out, but that's also the reason why we what we call varize the hips. So with surgery, we change the neck R-shaft angle from typically about 140 to 150 degrees down to 115 degrees, okay, in severely disabled children. So that gives us a good head start, and then after that, the children don't need much hip abduction anymore. But with abduction, we mimic the normal relationship between the socket and the neck and the ball of the thigh bone. Okay. Often what helps is because how do we get there? We still need to release some muscles at an early stage. We do bone surgery only at a very late stage, typically around the age between six and eight. But soft tissue releases are important for those children at an early stage to allow the hip abduction to happen. Without that, and sometimes with Botox, you know, with Botox, we get the legs softer in a better position to allow this abduction to happen. And then we can buy time. This is about not having a perpetual fix or like a fix long term, but we know that these hips often deteriorate still over time, but we want to buy ideally a time until they are about six to eight years old, and we can do hip reconstructive surgery safely and long term. We have a good long-term result. But until then, I want a little bit more abduction because I cannot change the angle between the neck and the shaft in these early stages because I know with bony surgery that a relationship will return. So we have remodeling of the neck and the shaft in the future. So therefore, I advocate for at least 20 degrees of hip abduction each side to try to get the ball and the neck into a safe position.

SPEAKER_02 15:06

20 degrees each side. It's a tool, not a rule. So this is for all children who are non-ambulant until they are six. You would say because they're not weight bearing, you know, and and assuming that they it's safe, that they don't have high tone, where it's going to be dangerous. Yeah, so it sounds like there's a multiple reasons why children's hips migrate. Bone isn't the shape that we want isn't happening, and we can't do surgery yet. The bones haven't developed yet. So we want to abduct their legs 20 degrees until that happens. But it's not a golden rule for every child there's non-ambulent. It does depend on whether they are, if they're high-tone, then we don't want to do that. And if they're low tone, it sounds like we don't need to do that. Is that right? So even if they're low tone, we don't need to.

SPEAKER_00 15:46

So low tone children still, I mean, SMA, for instance, it's still uh best if they have a pathological relationship between the proximal femur, so the top end of the thigh bone and the acetabulum, I still want a little bit of hip abduction. But it's not so important because children with low tone, for instance, cerebropals, they have good hip abduction themselves. But for children who tend towards adduction on both sides, it's important to try to get them into a more physiological position. But what is also important in an in an older child, we have a problem with pelvic obliquity and with scoliosis. And older children often develop what we call a windswept deformity. And this is a real, real big issue because the windswept deformity drives one hip, the hip which is adducted out of the socket. But at the same time, when you sit the patient into a wheelchair, the pelvis rotates. GMF level 4 and 5, they have a risk of 80%, so 70%, 80% chance of developing a scoliosis. And we don't know what drives what. There could be a little bit of asymmetry in the hips, there could also be just a neurological scoliosis starting to happen, and then we we have more of a fixed rotation of the pelvis and obliquity. It becomes uh stronger and stronger. So if you look at the front, and this is actually really, really important, you see that the one if there's windsp deformity, that hip that is in A-deduction helps to push the same side pelvis backwards. So it helps rotating, but on the other hand, also the scoliosis helps rotating the whole pelvis, you know. So let's assume the right ASIS is forward, the left ASIS is backwards. Can you can you imagine this? So the left hip is then adducted, and we have a windswept deformity to the right.

SPEAKER_02 17:49

Okay. So your pelvis is essentially facing the left. So if you're if your pelvis was a face, your face is turning to the left, and then your left leg is coming in towards the midline or beyond the midline, it's going in, and then the right leg is also doing the same. They're both going to the right. The face of your hips is going left, and your knees are going right. Is that what you're explaining? Cool, continue.

SPEAKER_00 18:10

So the knee is going to the right, the left knee is going to the right, exactly. In the right hip. Yes. So often we have also an A at the same time, the hip A B ductors on the right side being stronger. And if you then try to adduct the leg, you actually increase the pelvic rotation with the right side coming further forward. Can you imagine this?

SPEAKER_02 18:35

Yep. So your right knee is going out to the side.

SPEAKER_01 18:38

It looks like the right leg, uh, you have a leg length discrepancy for people driving and just understanding how this concept's looking in your mind's eye. We have it's presenting like a leg length discrepancy where the right leg's longer than the left. Um, we're facing the left side, so everything's windsweeping to the right, but the body is kind of pivoting a little bit to the left. Okay, so we've got that wind sweeping. And what you're explaining is by naturally wanting to abduct the left leg. So because it we have that windsweeping presentation.

SPEAKER_00 19:11

A duct the left leg, obt the right leg. Okay. So in the windsympt deformity to the right, the right leg is abducted, that also happens in the wheel, or tries to happen in the wheelchair, whereas the left hip is adducted. So inwards and going maybe across the midline. So now we have a huge dilemma because the fissure tries to position the pelvis or the legs actually symmetrical. But that's something which we probably shouldn't do. We should allow abduction of the right hip, which is already abducted, and pushes the and rotates, helps rotating the pelvis. And then if possible, add abduction to the left side. Okay. If the hip adductors, exactly, if the hip adductors are not too tight, meaning you start with the right side basically out of the frame or out of the foot hangers. That's what we typically do. And then typically with well, we have to help this often with surgery to release of the left hip adductors, those muscles that bring who are contract and bring the leg inwards. So to reduce that one and this way also potentially reduce the hip or keep the hip in a better position. So in those children, we need actually more hip abduction than 20 degrees. That's what I'm saying. Okay.

SPEAKER_02 20:47

After surgery.

SPEAKER_00 20:49

Yeah, even well, in before surgery, the principle, the main principle would be to try to keep the pelvis neutrally rotated in the wheelchair. So both ASIS at the same point. And this this is something which I see almost every time in clinic, and it gives me big grief because it's not considered properly. So the most important thing is that the pelvis is really correctly rotated. And then you let the one which goes into abduction, but let it go into abduction because you need to this hip is safe. That hip is located. Because the hip abductors preserve that hip integrity, but the other hip is at risk. The hip which gets pushed into adduction, so the leg inwards, that is at risk of dislocating. And that then needs to have the ability to get out as fast as much as possible. Before the operation, you still can often get to at least neutral. So you need to try this. It will look asymmetrical because the right leg is abducted. And the left leg is probably only to the midline. But it's better to have the asymmetry of the legs here. And after surgery, have more abduction on the left, abducted and contracted side. And that may be that it's 30 degrees, for instance. Sometimes I have even more and have the foot hangers swapped. So I can actually then achieve more than 30 degrees of abduction, sometimes 40 degrees of abduction each side. You know, it looks crazy sometimes, but that's how you keep those children pain-free. And you know, once the situation is stabilized, sometimes with the help of a spine surgeon too, you may revert the child later on again, but as long as the hip disease is driving one hip out, it needs the best possible position in the wheelchair to prevent hip dislocation.

SPEAKER_02 22:55

I'll just share my screen and show you a before and after of a client and to explain exactly what Doctor is uh is talking about. What you're saying is basically, even if someone looks wrong, they might be right based on the hips. The priority is the hips. And so what you're saying is that we want a level ASIS so that one's not more forward than the other. And if that means we have to let one leg go or two legs go and it looks all the way out of the place, that's fine because the pelvis controls over the it controls your spine, it controls what's going on over here. So we don't want to sacrifice the the neutral position of the pelvis so we can have a nice looking legs. We let the legs go as if we have to. We want to bring the legs out, you know, if we that means one abduction, abduction is fine. The adduction one is probably a tricky one because if someone's contracted in an adducted position, like their knee is going over their midline, it's gonna be hard to bring them out of like what you said, Doctor, you could probably bring it to neutral, but we got to do something to do the opposite because the adduction is worse. Like we've already got hip migration, and now it's like a lever that we're pulling to like pop it out, pop it out of the socket, which is not what we want to do. So we've got to do something to get it back in the mimic the normal shape as much as possible. My question is, Doctor, I'm gonna show you probably the most common cushion that we use for children with disabilities is a contoured cushion that allows the legs to be straight, right? This and often as clinicians, wheelchair prescribers, we look at this and say, we want the kids' hips to be neutral, so we put them in a contoured cushion that is straight. For those who can't see what I'm doing, I'm just showing a specs cushion right now, a high contour cushion because it's a very popular cushion, could be a dreamline, could be any other brand. Um, but essentially it's straight, where the hips are being flexed, they're kind of internally rotated, um, because you know that's what straight is. Is this what we want to be doing as a general rule, or should we be looking at cushions with more of an abducted, a slightly more abducted shape? Is this good for general or is it unlikely that some our children who are non-invalent should be in cushions like this?

SPEAKER_00 24:49

If you in these cushions look at the width of the pelvis and then look at the width of the thighs, it's the same. Meaning these the hips in these cushions, yes, it looks like a pommel in the middle, you know, but the hips are just at neutral. I see, in particular when I see patients who just have an increasing what we call migration index with the hips slowly coming out, and I see this cushion. I want the hips to be in a little bit more of A Bduction. But with those pillows and cushions, I can't achieve it. I can't just cut something away from the pillow and allow more hip abduction. What I uh need is actually a more adjustable wheelchair where I can actually adjust thigh guides and also have the cushion contour on less contoured, so it allows me a wider range of hip abduction or from little abduction to a little bit more hip abduction. And for that reason, I personally prefer actually quite a flat pillow with a pommel and rather an adjustable pommel so I can actually get into the position I want the hips to be. That also means that I'm sometimes uh, yes, I know the uh width of the wheelchair is often determined by the width of the pelvis, but I need the thigh guides to be adjustable and abeductible, in the wheelchair. I I would like to have a wheelchair that has maximum adjustability. And yes, exactly. You show you show some of the uh examples here, that's fantastic.

SPEAKER_02 26:37

Uh I'm just uh pulling up a specs constructor cushion that has a nice little keyhole. It's kind of like a hole where you can twist it and you can put a pommel in there and you can flex it. And whilst that's good for the cushion, exactly what you're saying, Doctor, the wheelchair doesn't accommodate that either. So it's quite tricky.

SPEAKER_00 26:53

We have a certain position of the footrests. Often it's only one footrest where where the board, the the bottom board where both feet are resting on is actually one part. And um you can't just widen the footrests easily or change the position, the width of the footrests. And sometimes, and actually quite often, we help ourselves of swapping the footrests so that then the feet are on the outside of the frame, which maybe is often in many cases actually too much, but we have no other choice. So we have to have more adjustability at the frame section to allow changing widths of the feet on the footrest, or as you just pointed here out, a footrest that is separable, so uh right and the left footrest, and not just one board, which uh well seats or allows both feet to rest at the same time, you know. So that's for me the worst case scenario and the least adjustability.

SPEAKER_02 27:56

So a couple of things from a product perspective, Doctor, just this might make you feel better. So this chair that you see over here, this is a quickie iris, and this is called a contracture kit, where these leg wrists can actually slide in and out. So the the post is on the side and we can slide them in. So what that means is that we could have these posts in the middle and we can have the foot plates on the outside, so we can actually adjust how much that comes out. Not a lot of people do this because it's not designed for that, but it's super helpful. Like you can see from here, you could slide it. So we could slide these set this post in the middle of the chair and have the foot plates on the outside, which means we can adjust whatever abduction that we want. The second thing I want to show you that I think is interesting, this is a cushion mostly used for adults, but it's a very nice cushion because it's actually wider at the front than it is at the back. For those just listening, this is a true comfort to cushion. Not typically used in pediatrics. In fact, the small size it can go into is 16, um, or maybe 14 actually. But I love the cushion because it's it is narrower at it's say if you had a 14 inches wide at the back, it would be 16 at the front, and then it has a bit of a pommel, and it also the shape of it allows for a little bit of external rotation. I don't know if you want that, but it's a very nice, comfortable cushion to sit in to for adults. And I'd love your opinion as to whether or not this would be a good cushion for children.

SPEAKER_00 29:10

All right, first of all, it's a good starting point, and because the thighs are round, uh, they always want to fall back into the same position. As I said, this is a good starting point. If you have the normal cushion you presented earlier, that doesn't allow more hiblection because uh the uh the bottom area of of the thigh is always at the same point. And if you push the legs out, then it would sit against the side walls of the put of the cushion, which is not good. The worst. Exactly. The other thing is what is very important. I don't want external rotation whatsoever. I want I don't want the knees out and the feet in at the foot at the narrow footrest. Because you don't want frog legs. I don't want that. Why is that? I why is that? Because with the anteriors or interversion of the femoral neck, the femoral neck and the head comes more to the front. More to the front and pushes against the acetabulum even harder. I want rather mild internal rotation that allows the the neck and the ball of the thigh bone to seek s to sit deep in the socket. I want at least neutral position with preferably even very mild internal rotation. That's uh the best uh way to for the for the thermal balls to rest in the socket.

SPEAKER_01 30:41

That's really great. I'm thinking, um, so if we had that rotation and we and you mentioned about the feet, so imagine we're in that frog-leg position, okay, and you're saying quite understand, we don't want that. We want to be able to derotate because we're in rotation, you don't want rotation, you want to derotate. What essentially would happen though, is from my experience and just me trying it as I'm sitting here, is that the feet, when you derotate, so if we're in that rotated position, if we derotate, we're going to bring the knees, we're going to add up, we're going to bring the knees sort of closer to together just naturally. We're not going to be able to control everything to have it into full sort of symmetrical midline. But essentially, would you accept the uh sort of the because of the rotation or derotating there, the feet might go slightly splayed out because of that? Because if you bring that rotation in, the knees essentially are going to come closer together and the and you're going to have more of a splay at the bottom. Is that something that you would um be comfortable with um sort of accommodating rather than correcting, if that makes sense, going with that and having that sort of presentation?

SPEAKER_00 31:57

So I'm actually happy if the uh foot width is as wide as the knees. So knee width is as good as the foot width. Then we have neutral rotation. Internal rotation may actually not be liked by the patients because often the external rotators at the hip, because they'll sometimes it can be that they uh like to be in frog leg position. That means that over time, muscles at the hip joints, so the external rotators, they become tight. And they they may resist or find it not comfortable to have the knees in and the feet out. So for me, actually, as a general rule, the best position would be if the knees would have the same width like the ankles. That means that the that the footrests have to have really the same width like the cushion has and also the thigh guides.

SPEAKER_02 32:54

I want to tie this on to adults as well. And this is one of my clients who would love some opinion on this. Doctor, I just want to quickly show you. She has a a subluxation in her right hip in this case. So in this case, do I just leave it? Or is it better to try to still abduct it? At this point, what do we want to do with this subluxed tip? Just leave it or try to fix it?

SPEAKER_00 33:16

Well, so we have a big dilemma. If it's a subluxed tip, the ball rides often at the acetabular rim. If you now abduct that hip, you tense up and stretch the hip adductors, the muscles that move the leg inwards, that increases the pressure of the femoral head against the acetabular rim and and causes pain. So you can't do that. You can only do this if you salvage this situation. Either reduce the hip, release the muscles, or sometimes as a salvage percentage, which I occasionally have to do. Unfortunately, you remove the ball surgically. So it won't ride against the acetabular rim. And that's probably the most in the most uh terrible pain these patients can have. So if you if you forcefully abduct the hip, you actually make the whole situation much worse. So you can't do it. Yeah.

SPEAKER_02 34:14

That's good advice. Just so everyone knows the cushion that we did go with, I don't have cushion, was one of these. This is Specs constructor cushion, where if I did a side-by-side screen, you'd be able to see that this is like a clear example where it looks like a leg length discrepancy where we'd want it shorter on the right side, but it's not really shorter, it's just because it's subluxed and it the bone's further back. So we've gone shorter on the on her right side and longer on her left side, and we've uh you know, we've tried to do our best to adjust her leg over here. She's got these extra wide foot plates. This is as wide as these foot plates go, but we are trying to get her foot under her ankle. So it's good to know we're on the right track, but it's just interesting. Like I'm sure a lot of clinicians would meet people in cerebral palsy where we didn't know the knowledge that we know now, and kids were just left to their own devices, and then they get these very difficult situations. So the idea is obviously to prevent this, but if we get this, then we just need to accommodate the position as best as possible without putting people in pain. Pain is the number one thing that we want to prevent.

SPEAKER_01 35:09

I think we'll probably need to sort of round this up for this episode, but we would love to invite you back on if you were so in any position to give us any more time, because there's so much that we need to discuss about the practical application. So the theory, and then how do we apply that? Exactly what Justin was just um describing with you and showing how he went from a presentation to actually applying that within a wheelchair base and then moving forward. So I think in closing, uh, from my side, it's been unbelievable to actually gain this knowledge directly from an orthopedic surgeon, somebody who's working every day in this area and is hugely experienced within that. Justin, anything from your side that you want to say or close up with?

SPEAKER_02 35:57

No, that was just really uh really helpful, Doctor. And it is a challenge, like there is a conundrum of what you're proposing, like, especially when we've got active kids in manual wheelchairs where they're the leg rest, we can't move, like we can't always do these things, but at least we know what the North Star is and we can work backwards from there. We're trying to do this and we can come with creative ways to do it. And I'd love to work with manufacturers uh to build products like this because it seems like most children, just to summarize, most children who are non-ambulent, meaning that they're not walk-in, should be in some level of abduction. And although the one I showed you, which does have a bit of abduction, uh, it causes a bit of external rotation. We don't want external rotation at this young age. So something in between, you know, Medifab, Sunrise, Autobok, Invicare, whoever wants to chat, let's chat. If we can make a cushion, we'll call it the axe cushion. That'll be it. That's the cushion. Let's call it that.

SPEAKER_01 36:47

I think in closing, there clearly is a huge educational need that needs to be continued because we, as providers of the equipment who are assisting the occupational therapists and the physiotherapists, really need to be collaborating even more than what we are. I think that's what I'm going to take from today is education, education, learn, learn, learn. Let's get the basic principles of seating and how we're going to actually use theory and collaboration to get that practical solution. I think that's a great way to end. Um, Dr. Axt, it's been an absolute pleasure. Without putting you under too much pressure, would you come back on or consider coming back on again? Anton, thanks very much for the invitation in the first place.

SPEAKER_00 37:35

Yes.

SPEAKER_02 37:36

Now, I'll say, Dr. Axe, I actually think this will spark a bit of conversation, and I'm sure people will reach out to us with questions and clarification points. So we'll um we'll reach out maybe in a couple months once the dust has settled and we've got some uh fresh ideas to chat about. But thank you again, Doctor. We really appreciate your time. I can't imagine how busy you are with all your experience and what you're doing at the hospital. But we again really would just appreciate your time.

SPEAKER_01 37:57

Brilliant. Thanks everyone for listening to uh Wheel Chat. Uh, you've been listening to Justin Bulos and Anton Mitchell. We are back for season two. Get ready. This is just the start, and we're very, very excited. But don't forget, it's so important to click like and just subscribe to the channel. Subscribe. It's more important than you guys realize. I know that a lot of pods actually say that, but genuinely, the more we're doing this, the more we realize how important it is to get people like Dr. Axt on the pod so that we can just continue to learn, learn, learn. Guys, have a great rest of your day or beginning of your day or finish of your day. Whoever's listening, we can't wait for uh next episode. Check us out. Thanks, guys.

SPEAKER_00 38:42

Thank you. Thank you.