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Cerebral palsy and its sequelae.. (consequences).

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1 Cerebral palsy and its sequelae.. (consequences)

2 Cerebral Palsy Was first described by William Little in Then it was known as Little disease. The term Cerebral palsy originated with Freud. Definition In all cases the following must be true… Cerebral palsy is the result of a brain lesion. Therefore, the spinal cord and muscles are structurally and biochemically normal. The brain lesion must be fixed and non progressive. Thus, all of the progressive neuro degenerative disorders are excluded from the definition. The abnormality of the brain result in motor impairment.

3 Epidemiology The Incidence is between per 1000 live births. The risk of cerebral palsy in a child born full term is app.1 in The incidence has been correlated with gestational age and birth weight.

4 Etiology Divided into 3 time periods… Prenatal Maternal infection and toxins (TORCHES). Fetal exposure to drugs and alcohol through maternal.(cocaine, heroin,marijuana) Congenital malformations of the brain that occur during early pregnancy. Rhesus blood group incompatibility resulting in kernicterus. Maternal health problems. ex: RF-Infections. Prenatal chorioamnionitis and maternal infections and placental abnormalities. Perinatal Anoxia as a result of perinatal complications. Fetal distress. Premature delivery. Sepsis in neonatal period. Bronchopulmonary dysplasia and prolonged ventilation in preterm infants. Heart surgery before the age of 1mnth. Postnatal Infections in early childhood (meningitis). Any episode of hypoxia. Trauma and head injuries.

5 Classification Physiologic classification Describes the type of movement disorder present… Spasticity: the most common. Increased tone in the extremities.. (the Clasped knife model) Hypotonia: usually a phase, leading most frequently to spasticity. Dystonia: lead pipe model. Athetosis: abnormal writing movements, patient cannot control. Ataxic: in cerebellar lesions. Patients frequently have a mixed form of movement disorders. Geographic classification Describes what part of body is affected..  Hemiplegia: one side, upper usually more involved.  Diplegia: both sides, with both lower extremities and lesser involvement of upper extremities.  Triplegia: both lower and one upper extremity.  Quadriplegia: Total body involvement.

6 Spastic Diplegia Spastic quadriplegia

7 Evaluation Diagnosing.. Obtaining a complete history (birth history, birth weight, complications following birth..) Asking about the child’s preferential use of one hand or leg. Related medical conditions (seizures, speech disorders) Physical examination.. Increased muscle tone. Deep tendon reflexes are increased. Fine motor activities testing. Retained infantile reflexes. Balance, sitting and gait of child.

8 Treatment Treatment, Surgical or nonsurgical, must be goal oriented.. The goals of treatment that have linked to productive lives as adults are: Communication, education, mobility and ambulation. Treatment ranges from observation, physical therapy, medications.. to surgery.

9 Treatment.. Physical therapy.. Often the first rendered to the child with cerebral palsy. No controlled studies have confirmed that regular physical therapy improves the out come of the child with cerebral palsy. The approach to physical therapy is to establish a therapy to monitor the developmental milestones of the very young child around the age 2-3 years. Therapy continue if gains are being made in attaining ambulation.

10 Treatment… Casting.. Short leg casts are applied with extended toe plates, careful molding of the heel and metatarsal head control. For a period of time varies but usually a minimum of 6 weeks. and is followed by the use of orthoses. There is a limited role for casting in patients with cerebral palsy. Orthoses.. Can be helpful in improving gait in ambulatory patient with cerebral palsy. Ankle-foot orthoses are most commonly prescribed to assist the child with positioning of the ankle and foot during gait.

11 Ankle Foot Orthoses (AFO)

12 Cerebral palsy The upper limb surgery

13 The upper limb The basic goals can be achieved with operative treatment of upper limb.. I. Improvement in function. II. Improvement in appearance. III. Facilitates nursing care in children who are unable to care for them selves because of more severe involvement. The major surgical methods… Lengthening of a tight musclotendinous unit. Augmenting a weak muscle by tendon transfer. Arthrodesis in the older children.

14 The upper limb.. Non-surgical treatment.. Directed towards.. Preventing of contracture. Splinting for positional improvement. Hand therapy to improve dexterity. Sensory reeducation. Muscle relaxants( as Baclofen or Botox) affect in decreasing spasticity. Surgical treatment.. Most procedures attempt to restore balance by combination of soft tissue releases and tendon transfer, or by arthrodesis where soft tissue procedures are inadequate. The typical posture of spastic upper limb is…elbow, wrist and fingers flexion, and forearm pronation.

15 Flexed wrist and hand with pronation of the forearm

16 Elbow flexion contracture Occurs usually in the globally involved child. Shoulder adduction contracture may be present Severe elbow flexion contracture can be relieved by… i. Release of the lacertus fibrosis. ii. Z-lengthening of biceps tendon. iii. Lengthening of brachialis tendon. iv. Proximal origin of brachoradialis m. can be released. Loss of some active flexion may happened.

17 Mital elbow flexion release

18 Forearm pronation  Develops insidiously, and with growth, causes a rotational deformity of radius.  The release or rerouting of the pronatore tendon is the option for correction when the fore arm is passively correctable.

19 Fractional lengthening of pronator teres at its insertion to the radius.

20 Wrist and fingers flexion The goal of surgical procedure on the wrist and fingers is to allow the fingers to open with wrist flexion for release, and to close with wrist extension for grasp. The lengthening of the wrist flexors, flexor carpi ulnaris at the intramuscular level, Z- lengthening of flexor carpi radialis, release of palmaris longus and super fascia and with fractional lengthening of the flexor profundus. all that will allow the wrist to be brought into extended position. The extensor carpi ulnaris is the preferred tendon to transfer into the extensor carpi radialis brevis. Severe deformity: especially in non functional hand, wrist arthrodesis is a solution for hygiene and care problems.

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23 The thumb Thumb-in-palm deformity is common in cerebral palsy patients. The deforming forces are: adductor pollicis and all the intrinsic muscles.  The approach is to release contracted soft tissue and then augment weak extensors and abductors by… 1. Simple release of the contracture when child demonstrates active thumb interphalangeal extension and a palpable extensor pollicis longus. 2. Release of the origins of the thenar musculature, and the two heads of adductor pollicis. 3. Release of the first dorsal interosseous fascia with release of the thumb-index web space.

24 Deformities of thumb in cerebral palsy Release of the origins of intrinsic muscles acting on thumb.

25 Cerebral palsy The lower limb surgery

26 Foot surgery

27 Foot surgery Equinus  It is an increased plantar flexion due to a plantar flexion contracture or dynamic plantar flexion due to over activity of the gastrocsoleus during gait.  Toe-walking patients must be considered as two different groups: i. equinus patients. ii. as a consequence of crouch at the hip and knee with natural ankle.  Cerebral palsy must be differentiated from: A. Idiopathic toe walking as a congenital short Achilles tendon B. Muscular dystrophy (as Duchenn’s)produces toe walking.

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29 Equinus.. Clinical examination.. Of the child with equinus due to cerebral palsy shows inability to fully dorsiflex the ankle. The Silverskiold test: If the ankle can be passively dorsiflexed with the knee bent to 90 deg. but cannot be dorsiflexed with the knee extended.. It’s felt that the gastrocnemius is tight, but the soleus is not contracted. This test is used to determine which type of surgical lengthening to perform.

30 The Silverskiold test

31 Equinus… Leads to…  Gait is less efficient.  Foot drop results if anterior tibialis is unable to lift the foot to natural during swing phase.  Genu recurvatum is seen.  Valgus positioning of the hind foot.  Calcaneus is actually in equinus.  Pain and callosities result over the head of talus.  Hallux valgus can develop.

32 Surgical treatment of equinus  It is selective lengthening of the Achilles tendon or the gastrocnemius.  It is believed that a gastrocnemius recession should be performed when Silverskiold test (performed under anesthesia) is positive and dynamic EMG shows more abnormality of the gastrocnemius than the soleus during gait.

33 Surgical treatment of equinus.. Achilles tendon lengthening Casting is necessary. 3. Can be done per cutanously. Gastrocnemius recession.. 1. Preserve push-off power. 2. Immobilization is minimized following operation. 3. Open methods. 4. Almost no risk of over correction. 5. Greater recurrence rate (up to 48%)

34 Gastrocnemius recession techniques 1. Vulpius technique.. 2. Strayer procedure 3. Baker technique.. (tongue-in-groove)

35 Vulpius technique.. Strayer procedure

36 Baker technique

37 Achilles tendon lengthening techniques 1. Open technique.. with Z-fashion lengthening 2. Per cutaneous techniques.. White.. Two-cut technique. Hoke.. Three-cut technique.

38 Z lengthening of Achilles Tendon

39 Hoke per cutaneous Achilles T. lengthening

40 Equino varus deformity  Muscle imbalance in which the invertors of the foot over power the evertors. with the gastrocnemius contributes equinus.  Surgery is indicated to.. 1. Improve foot contact. 2. Relieve pain. 3. Relieve skin changes.  Tendon surgery can be done if the foot can passively corrected with manipulation to the natural position.  Bony surgery is necessary when the deformity is stiff and cannot be manipulated into a plantigrade position foot.

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42 Equinovarus deformity.. The confusion test: The patient flexes the hip against resistance.. If the supination of the forefoot is seen, the a.tibialis is contributing to equinovarus deformity.. When dorsiflex is seen without supination, the deformity is less likely to respond to surgery on the a.tibialis.

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44 Equinovarus surgery p.tibialis tendon lengthening  Usually done in conjunction with Achilles tendon lengthening.  It is done In young patients with mild varus with equinus.  Can be performed as intramuscular lengthening or as tendon Z lengthening.  Complications.. I. Recurrence of the deformity. II. Development of postoperative valgus.

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46 Equinovarus surgery Transfer of the p.tibialis tendon to the dorsum It is not a preferred procedure because of its disastrous complications: heel valgus in 68% of patients.

47 Equinovarus surgery Split p.tibialis tendon transfer  Popularized by Kaufer& Green.  It is one of the most common procedures for equinovarus deformity treatment.  The posterior one-half of the p.tibialis tendon is rerouted posterior to tibia and woven into the peroneus brevis tendon.

48 Kaufer split transfer of tibialis posterior tendon

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50 Equinovarus surgery Split a.tibialis tendon transfer  The lateral one-half of a.tibialis is detached from it’s insertion.  Passed beneath the extensor retinaculum.  Inserted through a bone tunnel into the cuboid.  Foot is positioned in 5-10 deg. of dorsiflexion.  Known as the Rancho procedure when done in combination with p.tibialis lengthening.

51 Hoffer of split transfer of tibialis anterior tendon

52 Equinovarus surgery Bony surgery  Its done where the varus deformity is fixed.. and the p.tibialis tendon lengthening would not provide correction.  Heel varus will respond to calcaneal osteotomy.  If the deformity is severe, and with rigid component of mid foot supination… Triple arthrodesis should be performed.  Even with bony procedures, muscle imbalance must be corrected.

53 Dwyer closing wedge osteotomy of calcaneus for varus heel

54 Pes valgus  Occurs in up to 25% of patients with cerebral palsy. and most common in older diplegic or quadriplegic patients.  Can be caused by spastic peroneal muscles, weakness of the p.tibialis and a tight gastrocsoleus.  Radiographs should be obtained in standing position for the foot and ankle.  Conservative treatment should vigorously pursued.. shoe inserts and orthoses may be adequate to relive pain and avoiding surgery.

55 Pes valgus

56 Surgical treatment of Pes valgus  Bony surgery is the only predictable alternative for full and lasting correction.  Surgical options are… I. The Grice extra- articular arthrodesis. II. Lateral column (calcaneal neck) lengthening. III. Calcaneal osteotomy. IV. Triple arthrodesis.

57 Surgical treatment of Pes valgus Grice extra- articular arthrodesis  First described by Grice in 1952 for correcting Pes valgus in young polio patients in the age of 4-12 yrs.  Then widely used for correction of Pes valgus in children with cerebral palsy.  Satisfactory results reported in 79% of patients.  A graft is propped into the sinus tarsi laterally to support the plantar flexed talus and correcting valgus of subtalar joint.  Advantage: does not interfere with the growth of tarsal bones.  Failures are due to: 1. Persistent valgus. 2. Overcorrection into varus. 3. Ankle valgus. 4. Graft slippage. 5. Graft nonunion.  Modifications to the original procedure:  Fibular graft was changed to iliac crest graft.  Using internal fixation to keep the position of the subtalar joint in combination with cancellous iliac crest graft.

58 Grice extra- articular arthrodesis

59 Dennyson and Fulford technique of Extra articular subtalar arthrodesis

60 Surgical treatment of Pes valgus Lateral column lengthening First described by Evans. Correction is achieved by lengthening the calcaneus, and therefore the lateral column of foot, effecting tightening of plantar fascia and reduction of the lapsed talonavicular joint. Achilles tendon and peroneal tendons must be lengthened.

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62 Surgical treatment of Pes valgus calcaneal osteotomy Advantage: preserve joint motion of sub talar joint. Results have been very good. Contraindications: severe rigid valgus deformity.

63 Baker and Hill osteotomy of calcaneus to correct heel valgus

64 Medial displacement of calcaneus for hind foot valgus

65 Surgical treatment of Pes valgus Triple Arthrodesis Treatment of choice for rigid symptomatic Pes valgus in adolescent with cerebral palsy. Resecting the subtalar, calcaneocuboid, talonavicular joints. Indications: 1. Pain 2. Skin ulceration over the talar head. 3. Deformity interfering with ambulation in child with deformity not amenable to osteotomy. Satisfactory outcomes are found when deformity is well corrected. Degenerative changes have been documented in the ankle joint at an average of 18yrs.following arthrodesis in 43% of the pediatric population.

66 Triple arthrodesis for Pes valgus treatment

67 Ankle valgus  Valgus alignment of the ankle develops in patients with neuromuscular diseases.  Radiographs of ankle in standing should be obtained before surgical correction of Pes valgus.  Surgical correction is done by.. I. Hemiepiphysiodesis of the distal medial tibia (medial screw, staples or open epiphysiodesis) II. Osteotomy  Osteotomy is useful when immediate correction is desired.  A Closing wedge osteotomy of distal tibia, combined with distal fibular osteotomy is performed.

68 Hind foot valgus Subtalar arthrodesis Ankle valgus Medial Epiphysiodesis with screw technique

69 Dorsal bunion It is a rare deformity. The first metatarsal head is elevated, but the great toe is plantar flexed. Surgical rebalance depends on…  Transfer of the flexor tendon to the extensor.  Or flexor tenotomy.  Or by transferring of the flexor hallucis brevis to the metatarsal neck  Or by all that in combination with closing wedge plantar flexion osteotomy of first metatarsal.

70 Hallux valgus Develops in cerebral palsy patients in response to a Equino valgus deformity of the hind foot. There is a progressive eversion and abduction of foot because of peroneus longus is spastic. The toe is pushed laterally as weight is borne by the everted foot. The big toe comes to lie beneath the second toe, and the first metatarsal head becomes uncovered and painful bunion develops. When this deformity is mild, surgical treatment of Pes valgus will halt the progression of toe deformity. Bleck& Goldner described soft tissue realignment including: Release of the adductor hallucis t. and lateral capsulotomy of the first metatarsophalangeal joint. combined with first metatarsal and proximal phalangeal osteotomy. McKeveer technique:  First metatarsophalangeal fusion.  That led to better results with less recurrence than soft tissue realignment.  Preferred position for fusion is deg. Of dorsiflexion and slight valgus.

71 Hallux valgus in 14 yrs. Old girl with cerebral palsy. Treated with metatarsophalangeal fusion.

72 Knee surgery

73 Consists of…  Hamstring lengthening.  Rectus femoris transfer.

74 Hamstring lengthening The hamstrings are nearly always affected in cerebral palsy patients, and tight hamstrings lead to crouch gait. Hamstrings cross two joints, at the hip they serve as extensors, and at the knee they serve as flexors. The popliteal angle measures the hamstrings spasticity and values greater than 50 degrees are considered abnormal in children of 4yrs and older. (normal is about 26 degs.) Fixed knee flexion contracture develops in severe hamstring contracture. That leads to disappointing results following hamstring lengthening. The Egger’s procedure has been historically used for the correction of spasticity in the hamstrings and crouch knee, but genu recurvatum was a frequent complication.

75 Holt’s method of determining hamstring contracture

76 Method of determining hamstring tautness Fixed knee flexion in a teenager boy with spastic quadriplegia

77 Egger’s transfer of hamstrings to femoral condyles.

78 Hamstring lengthening.. Surgical lengthening of the distal hamstring is now the preferred surgical treatment for crouch knee gait and is often performed in combination with other soft tissue procedures.  With intramuscular aponeurotic lengthening of semimembranous,  a Z-lengthening of semitendonosus  and either tenotomy or Z-lengthening of the gracilis at a level just proximal to the knee. An adequate lengthening has been accomplished (intraoperatively) when the popliteal angle is reduced to around 20 degs. Greatest improvements in the knee flexor contracture are seen within 1 year following surgery.

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81 Rectus femoris transfer Spasticity in the rectus femoris is tested by the Duncan Ely test. The surgical treatment for stiff knee gait and inability to flex the knee in swing phase is a rectus femoris transfer. Often performed simultaneously with hamstring lengthening and other soft tissue procedures. Current indications for distal hamstring lengthening with rectus femoris transfer are: 1. Significant crouch gait during stance phase with limited knee extension at midstance. 2. Increased popliteal angle and positive rectus femoris grab on clinical examination. 3. If EMG shows activity in the rectus femoris during swing phase. 4. In the case of sufficient hip pull-off power generation at late stance phase. 5. For velocity greater than 60% of normal. 6. If there are no significant rotational abnormalities of the hip that interfere with gait.

82 The Duncan Ely test

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84 Rotational osteotomies Spasticity in the lower extremities leads overtime to the development of rotational abnormalities in the femur and tibia. Persistent femoral anteversion is present in patients with spastic diplegia, and in some patients with severe spastic hemiplegia. Physical examination shows increased internal rotation and decreased external rotation of the hip. Overtime, compensatory external rotation of the tibia develops. Internal tibial torsion may be present in children with cerebral palsy, specifically patients with spastic hemiplegia. This torsion can be quantified by examining the bimalleolar angle.

85 Rotational osteotomies.. The best correction of rotational malalignment of the lower extremity is achieved by derotational osteotomies. Femoral anteversion is treated with inter or subtrochanteric level osteotomy or at the supracondylar level. In the case of tibial rotational deformities, surgical correction should be performed at the distal level.

86 Bilateral rotational osteotomies (tibial torsion) Distal femoral osteotomy for anteversion

87 Hip surgery

88 Hip surgery in cerebral palsy can be divided into three areas:  Correction of hip flexion contracture.  Correction of increased hip adduction during gait or scissoring.  Surgery to treat the subluxating or dislocating hip.

89 Hip flexion contracture surgery Hip flexion contractures are found most commonly in patients with spastic diplegia and spastic quadriplegia. Flexion contracture is due to increased tone in the hip flexors (primarily the iliopsoas) and relative weakness of the hip extensors (such as the gluteal muscles) The contracture is identified during the physical examination by performing the Thomas and Staheli maneuvers. The sacro-femoral angle is used to objectively quantify of the hip flexion contracture. Normally should be between degs.

90 Hip flexion contracture surgery.. The surgery in a walking child is done to improve the hip flexion contracture, and to prevent increasing hip flexion and anterior pelvic tilt when hamstring lengthening is performed. The recommended procedure is a psoas tenotomy done over the pelvic brim. Release of the iliopsoas tendon off the lesser trochanter should not be done in ambulatory patients. Bleck advised against simply releasing the iliopsoas, and suggested attaching the distal iliopsoas tendon anteriorly into the hip capsule.

91 Thomas test Staheli test

92 The sacro-femoral angle

93 Adduction contracture surgery Spasticity in the adductor muscles in cerebral palsy results in a narrow base of gait and scissoring. Over time, the untreated adduction contractures, when combined with hip flexion contracture lead to progressive hip subluxation and possible dislocation. The muscles leading to the adduction contracture are: I. The adductor longus II. Adductor brevis III. Adductor magnus IV. gracilis V. Occasionally the pectineus Clinical examination reveals inability to abduct the hips in flexion and in extension. Increased femoral anteversion when combined with crouch at the knee can produce the appearance of scissoring which termed as pseudo adduction.

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95 Adduction contracture surgery.. Adductor surgery will be ineffective in improving the child’s ability to walk when the narrow base of gait is secondary to pseudo adduction. Surgery to improve adduction contracture is limited to adductor release, with or without obturator neurectomy, and posterior adduction transfer. Adduction release is commonly performed in the young child with cerebral palsy who is able to stand with support but has difficulty walking because of scissoring. And its advantage is that it is a simple and quick procedure resulting an increased abduction and improved scissoring.

96 Adduction contracture surgery… Banks and green described this procedure by..  Detaching the adductor longus tendon from its origin on the superior pubic ramus, often along with at least part of the add.brevis and the gracilis tendons.  The add.magnus is not released.  Anterior branch of obturator neurectomy should not be performed. Further surgery is necessary with growth in 10-37% of all children who undergo adductor release. Perry advised a procedure in which the add.longus, add.brevis, and gracilis tendons are transferred from the pubic ramus to the ischium. In the Beals modified adductor transfer, the adductor longus and brevis are sutured into the lengthened gracilis, which remains attached to its origin.

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98 Posterior transfer of hip adductors to ischium

99 Hip subluxation/dislocation surgery hip dysplasia or instability is a common problem occurring in about 21% of cerebral palsy patients. Reports shows a prevalence of subluxation or dislocation ranging from 3 to 47% in cerebral palsy patients. Patients with spastic hemiplegia rarely develop hip dysplasia and dislocation. Patients with spastic diplegia are at increased risk. Patients with spastic quadriplegia have the highest rate of hip instability. The mean age at which patients with cerebral palsy present with subluxation or dislocation is 7 yrs. Hip subluxation develops in response to muscle imbalance. Subluxation develops gradually, with increasing lateralization and proximal migration of the femoral head with respect to the acetabulum.

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101 Hip subluxation/dislocation surgery.. Bony deformity occurs in response to the spasticity. The normal remodeling of the femoral anteversion seen in normal young child does not occur in patients with cerebral palsy, and anteversion persists into adulthood. The neck-shaft angle becomes increased as coxa valga develops. Acetabular changes occur as the hip subluxates,with an increased Acetabular angle and erosion of the lateral lip of acetabulum Finally, changes in the shape of femoral head takes place, with superolateral and superomedial notching.

102 Hip subluxation/dislocation surgery… On physical examination: hip subluxation or dislocation can be suspected with the presence of: A. Loss of range of motion. B. Abduction will be limited to less than 30 degs. C. A hip flexion contracture is presence. D. Increased internal rotation and, E. Decreased external rotation of the hip. F. When a unilateral dislocation is present, a positive Galleazzi sign will be obvious. Radiographically, the diagnosis is confirmed.. 1. Subtle break in Shenton’s line and a mild uncovering of the most lateral aspect of the femoral head. 2. Reimers’ migration index. 3. Elevated acetabular index. 4. The neck-shaft angle is increased.

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104 Hip subluxation/dislocation surgery…. Treatment of hip dysplasia has the following goals: To provide a painless hip that allows stable sitting and positioning in the non ambulatory patients. To reduce the hip fully so that ambulation can continue without groin or hip pain in patients who can walk. For the hip that is subluxated, surgery is done to prevent dislocation. does treatment make a difference in hip subluxation and dislocation in the child with cerebral palsy? The first question to be answered is, does treatment make a difference in hip subluxation and dislocation in the child with cerebral palsy? Several studies shows great controversy with differing results. Bleck advocates surgical reduction of hip in cerebral palsy, stating that one-third of patients with hip dislocation develop pain.

105 Hip subluxation/dislocation surgery….. The next question to be asked is, does hip subluxation or dislocation lead to scoliosis? The conclusion is that there is a strong tendency for unilateral hip subluxation to occur in conjunction with pelvic obliquity, with most dislocations on the high side of pelvis. Surgical treatment is divided into three phases: I. Soft tissue surgery for the hip at risk. II. Reduction and reconstruction of the subluxated or dislocated hip. III. Salvage surgery for long standing painful dislocation.

106 Paralytic dislocation of L hip and scoliosis

107 Soft tissue release for subluxation of the hip at risk The hip at risk is defined as a hip that has significant adduction and flexion contractures but minimal subluxation with a migration index of less than 30% The patients are 5 yrs. old or younger. Surgical treatment is aimed at preventing dislocation of the hip. Soft tissue release of contractures is indicated when abduction range is less than 30 degs. and flexion contracture is more than 45 degs. The procedure consists of adductors release and iliopsoas lengthening or release.

108 Soft tissue release for subluxation of the hip at risk.. Out comes of the procedure are in general:  The early results were promising.  13% of hips treated had subluxated and there where no dislocations.  Dislocations was prevented in 80%  83%of hips with preoperative migration index of less than 40% that were treated by adductor release remained stable.  Hips with a preoperative migration index of greater than 50% had poorer results.

109 Soft tissue release for subluxation of the hip at risk… Iliopsoas transfer is not a recommended as a part of surgical treatment of hip instability in cerebral palsy patients. The current indications for adductor and iliopsoas soft tissue release in patients with hips at risk for dislocation include: Adduction contractures in a young child, no older than 5yrs. With limited abduction of 30 degs. or less. And a migration index of not more than 30%

110 Femoral osteotomy The most frequently performed procedure in the treatment of more significant hip subluxation is a femoral varus derotation osteotomy (VDRO). An osteotomy is performed at the intertrochanteric level, usually accompanied by a closing wedge taken medially and/or femoral shortening, and the femur is fixed in an increased amount of varus with internal fixation. The two most frequently used plants for internal fixation are.. Hip screw and side plate. 90 degs. blade plate.

111 Femoral osteotomy.. Release of soft tissue contracture must also be done to balance the forces across the hip. Hoffer concluded that VDRO is a good procedure for hip subluxation, but is inadequate to treat the dislocated hip in cerebral palsy.. Other studies advocate pelvic osteotomy in addition to VDRO if the preoperative migration index is greater than 70% No significant remodeling into valgus can be expected in patients operated on the age 8yrs or older. Complications for femoral VDRO… Recurrent dysplasia. Loss of fixation. Fractures. Delayed union and nonunion are rare. Heterotopic ossification can result.

112 R hip subluxation+ adductor release +VDRO

113 Combined femoral varus and pelvic osteotomies In cases in which a femoral VDRO does not provide adequate coverage or stability to the hip, pelvic osteotomy should be performed. The pelvic osteotomies used are.. Re directional osteotomies (such as the Steel an Salter procedures) Osteotomies that reshape the acetabulum (such as Pemberton and Dega osteotomies) Salvage osteotomies that increase the area of the acetabulum with non articular cartilage (such as the Chiari osteotomy and the shelf augmentation procedure. The two pelvic procedures with the longest historical use in patients with cerebral palsy are the Chiari osteotomy and the shelf augmentation procedure..

114 Combined femoral varus and pelvic osteotomies.. The Chiari osteotomy. This osteotomy is performed by making a horizontal osteotomy from the sciatic notch to a point just at the superolateral margin of the acetabulum. and the osteotomy is displaced medially so that the hip capsule lies over the lateral bony surface of the ilium. Indications for Chiari osteotomy were: Presence of severe subluxation or, The presence of moderate incongruity on arthrography following the femoral osteotomy.

115 Paralytic dislocation of R hip in cerebral palsy+ open reduction +femoral shortening +Chiari osteotomy

116 Combined femoral varus and pelvic osteotomies… the shelf acetabular augmentation procedure. As described by Staheli : A notch is made in the outer wall of the ilium just at the margin of the acetabulum, and a cancellous and cortico-cancellous strips of iliac crest are wedged into this notch above the hip capsule. This procedure is indicated in a hip in which spherical congruency cannot be achieved. and also helpful in hips in which there is global acetabular deficiency and a small articular surface. Studies of the results in cerebral palsy are encouraging, with hip stability obtained in 83-95% of patients. This procedure should not be performed in very young patients.

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118 Combined femoral varus and pelvic osteotomies…. The Dega osteotomy. A third pelvic osteotomy that is of particular benefit in hip dysplasia secondary to cerebral palsy. As described by Mubarak; 1. The osteotomy extends through the outer table of the ilium from the anterior iliac spine to the sciatic notch. 2. A bicortical osteotomy is performed only at the anterior-inferior iliac spine, and the inner table of ilium is not cut. 3. The lateral osteotomy is extended to the triradiate cartilage under fluoroscopic guidance. 4. The osteotomy is pried down laterally and posteriorly. 5. Wedges of bone graft prop the osteotomy open. A prerequisite for Dega osteotomy is an open triradiate cartilage. Dega osteotomy allowed excellent correction of the superior and lateral deficiency seen preoperatively. A similar osteotomy is used combined with a shortening femoral VDRO and aggressive muscle release.

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120 Combined femoral varus and pelvic osteotomies….. The indications for this combined procedure are: Failure of soft tissue release in a child less than 8yrs old. Subluxation, defined as a migration index greater than 40% in children older than 8yrs. A recent hip dislocation (within 2yrs.) A painful subluxated or dislocated hip without significant femoral head deformity. The benefit of Chiari, shelf augmentation, and Dega procedures is that they provide coverage posteriorly and laterally and improve the migration percentage and the CE angle of Weiberg. The Salter’s innominate osteotomy is not to be used in spastic dislocations.

121 Surgical treatment of the non reconstructable hip Surgical reduction of the dislocated hip in patients with cerebral palsy should be limited to those children who do not have significant bony changes in the femoral head. In the presence of arthritic changes and severe erosion of the femoral head, it is clear that the hip cannot be reconstructed. The indications for surgery in this group of patients include: 1) Hip pain 2) Inability to sit in a modified wheel chair. 3) Difficulty with perineal hygiene duo to contractures There are 4 surgical options: Proximal femoral resection. Valgus osteotomy of proximal femur. Hip arthrodesis. Total hip arthroplasty.

122 Proximal femoral resection interposition arthroplasty Described for the treatment of painful dislocations of the hip in non ambulatory patients… The abductors are sharply detached from the greater trochanter. An osteotomy is made across the level of 3cm distal to the lesser trochanter. The iliopsoas tendon is transected. The hip capsule is detached and sewn shut following removal of the proximal femur, to cover the acetabulum. The quadricaps muscle is sewn over the end of the femoral shaft. The abductors are interposed between the acetabulum and the femur. Patients is then placed in traction for 3-6 weeks.

123

124 Proximal femoral resection

125 Valgus osteotomy of the proximal femur Performed to allow the thigh to come out into abduction, allowing perineal hygiene. The femoral head is repositioned farther lateral from the acetabulum, so that the rubbing between the pelvis and the head is lessened.

126 Valgus osteotomy Anterior hip dislocation

127 Hip arthrodesis Surgical fusion of the hip is been performed in patients with painful dislocations of the hip due to cerebral palsy. The desired position of fusion in non ambulatory patients is 50 degs of flexion and 10 degs of abduction. Root used a combined intra and extra articular technique, with subtrochanteric osteotomy of the femur o allow positioning of the leg.

128 Total hip arthroplasty Root has been the greatest advocate of THA in patients with cerebral palsy. The ideal candidate for joint replacement is an adult with cerebral palsy who is able to walk, stand, or transfer. Patients should not have coexisting pelvic obliquity or scoliosis. Technical considerations are… The need to flex the acetabular component to provide posterior stability in sitting patients. The frequent loss of acetabular bone stock superolaterally, which requires bone grafting.

129 Anterior dislocation of the hip Occurs much less frequently than the posterolateral type. Two groups of children are at great risk: 1. Patients who have excessive adductors and hip flexors release, leading to extension and abduction contracture. 2. Children with severe neurological involvement with extension posturing. Symptoms: inability to sit in wheelchair due to extension contracture. and pain in half of those patients. On Physical examination.. the femoral head is palpable in the anterior groin. and the hip flexion is limited. In the radiograph, the hip may appear reduced as it lies anterior to the acetabulum. Treatment: Aggressive muscle release of proximal hamstrings, and If the patient is abducted, the abductors and short external rotators must be included. Varus shortening osteotomy of the femur is recommended, in conjunction with acetabular osteotomy to gain anterior coverage. The Pemberton osteotomy is useful here.

130 Cerebral palsy Spinal deformity

131 Scoliosis.. Spondylosis..

132 scoliosis  Affecting between 25-68% of patients with cerebral palsy.  Incidence is highest in non ambulatory patients, and who have total body involvement.  Patients with spasticity are at high risk, compared to other movement disorders.  The usual curve pattern is a long sweeping curve that extends to the pelvis. with the apex of the curve at the thoracolumbar junction.  Rotation accompanies the coronal plane curvature.  Scoliosis leads to difficulty in sitting, and in using wheel chair. with: pressure sores on ischium teberosities, and a hand dependent sitter.

133 Scoliosis.. Indications for spinal fusion are: Curves of more than 50 degs in ambulatory patients. Progressive curves of more than 50 degs in patients who are communicative and aware of their surroundings. Curves that interfere with seating and nursing in patients whose families desire surgical correction. Segmental fixation is preferred. The role in scoliosis due to cerebral palsy is to instrument and fuse long. The fusion extends from T2 to the pelvis in non ambulatory patients, and to the lower lumbar spine in those who walk. The Luque technique, which uses sublaminar wires at each level… Distributes the corrective forces equally through the spine. Allows greater correction and better sagital contouring, And there is less loss of fixation. Fusion of the spine to the pelvis is accomplished using the Galveston technique.

134 Scoliosis… The Dunn McCarthy technique is suitable for many cerebral palsy patients. Two S-shaped rods are placed over the sacral ala. with upgiong laminar hooks or pedicle screws placed more proximally. then segmental fixation is completed. The advantage is that the sacro iliac joint is not crossed, which leads to less movement and loosening over time. The anterior release, discectomy and fusion are recommended in: Younger patients with open triradiate cartilages. Severe, stiff curves. Curves over 70 degs. In patients which a stretch spine radiograph shows lack of correction of pelvic obliquity.

135 Scoliosis in a 11yrs. old boy (angle of 87degs) Using the Luque rods and sublaminar wires with the Galveston technique.

136 Scoliosis in a 13 yrs. old girl (angle of 79 degs.) Using the Dunn McCarthy technique.

137 Cervical spine spondylosis Develops in patient with athetoid type cerebral palsy. Symptoms: develop in late adolescence and early adulthood… Neck pain, arm pain. Weakness. Decreased sensation in arms and legs on examination. Deterioration in gait. Treatment: surgical, by anterior inter body fusion and postoperative immobilization with Halo vest. Or by combined anterior and posterior spinal fusion.

138 Rhizotomy Selective dorsal rhizotomy in which a percentage of the dorsal roots are severed at the level of cauda equina. Spasticity is improved by reducing the stimulatory inputs from the muscle spindles of the lower extremities that arrive via afferent fibers in the dorsal roots. Usually 25-50% of the posterior nerve rootlets from L2 to S2 are divided. The rate of good results following rhizotomy depends on proper patients selection… Candidates are younger than 8yrs. Must have purely spastic type. Should have no fixed contracture. Must be able to ambulate without relying on spasticity for strength. There is no weakness in the antigravity muscles or trunk musculature. Must have supportive families and be able to cooperate with postoperative physical therapy.

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140 Cerebral palsy Fractures

141 Bone mineral density is decreased in patients with cerebral palsy. Low levels of vit.D have been documented in up to 42% of children with severe cerebral palsy. Up to 74% of fractures occur in the femur,particularly at the supracondylar level. Treatment of osteopenia: A.Vit.D supplementation. B.Biphosphonate. Treatment of fractures: Usually by cast immobilization. Internal fixation in femoral shaft fractures.

142 Thank you all… THE END 22 nd -Aug-2006

143 MoKazem.com هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي. الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة. This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali. This site is not responsible of any mistake may exist in this lecture. د. مؤيد كاظمDr. Muayad Kadhim


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