Novel Brace for Hip Immobilization After Bladder Exstrophy Repair

An innovative orthopedic brace allows families to avoid the disadvantages of casts, external fixators and traction devices after bladder exstrophy surgery.

After bladder exstrophy repair — a complicated surgery to move a baby’s bladder from outside of the abdomen to the inside — postoperative hip position can cause tension on the incisions, making pelvic immobilization essential for proper healing. Traditionally, hospitals use one of three methods to prevent exstrophy incisions from reopening: traction devices, external fixators or spica casts — all of which have significant disadvantages and can be difficult to manage at home for 6 weeks.

When a urologist and an orthopedic surgeon at Nationwide Children’s Hospital chatted about their dissatisfaction with the standard of care several years ago, an idea was born. After a year collaborating with a durable medical equipment partner, Boston Orthotics and Prosthetics, the solution was complete: a novel, adjustable pelvic immobilization brace.

“Bladder exstrophy is one of the most complex and challenging conditions we treat,” says V. Rama Jayanthi, MD, chief of Urology at Nationwide Children’s and Clinical Professor of Urology at The Ohio State University College of Medicine. “Immobilization in the immediate postoperative period is important to help with closure, but none of the traditional methods for dealing with it are ideal, and parents find them all rather traumatic.”

All three traditional methods make it difficult to manage postoperative wound care, and parents dislike the severe look and cumbersome care requirements of each. Traction requires the child to stay in bed for 6 weeks. External fixation requires additional incisions for the placement of pins that may not stay in place well in the soft bones of very young patients, and may carry their own infection risks. And spica casts — the method previously used at Nationwide Children’s — can require revision if there is significant postoperative swelling. Each option also takes significant time to implement, resulting in considerable cost.

The goal of the brace was to eliminate some of these disadvantages while maintaining high-quality postoperative outcomes.

Kevin Klingele, MD, chief of Orthopaedic Surgery at Nationwide Children’s, worked with Boston Orthotics and Prosthetics to design a brace that would, in essence, mimic a spica cast, stabilizing the patient’s pelvis following osteotomy surgery, allowing access to the wound for evaluation and cleaning, offering speedy placement postoperatively, simplifying hygiene and diapering, and reducing parent apprehension.

The team has now used the brace on at least a half-dozen patients, all with excellent results, and have described the brace in a recent article in the Journal of Pediatric Urology. Each brace is customized for the patient, and the braces are now the primary post-exstrophy immobilization method in use at Nationwide Children’s.

“This innovative method of postoperative immobilization has quickly proven itself to be a safe and effective way of managing the postoperative exstrophy patient,” says Dr. Klingele, who is also director of the Center for Hip Preservation at Nationwide Children’s. He has developed multiple solutions for suboptimal orthopedic fixation and surgical challenges of pediatric hip conditions.

The team is tracking outcomes for patients receiving the novel brace. While it may take several years to make statistically significant claims about outcomes in comparison to prior methods for immobilization, anecdotal evidence to date is reassuring.

“Theoretically this method is leaving a lot to fate, in that parents could take the child out of the brace, but our early experience suggests that isn’t happening—all six kids have done great, with no complications whatsoever,” says Dr. Jayanthi, who emphasizes that the brace does not increase operative time, leaves incisions exposed for cleaning and inspection, and allows for quick adjustments in case of swelling. “It is also just less traumatic for parents to see their child in a brace instead of the other options. It’s a great advance—it’s easy and it works.”

Reference:

Morin JP, Fuchs M, Klingele K, Jayanthi R. Novel pelvic immobilization method following bladder exstrophy repair. J Pediatr Urol. 2024 Apr;20(2):318-319.

Image credits: Nationwide Children’s