1. Surgical Management of the Lower Extremity in Ambulatory Children With Cerebral Palsy
Dr Hisham Bamaga
Saudi Board ,A.F.S.A France
Pediatric Orthopedic Consultant
Alhada Armed Forces Hospital

2. Realizing the problem vicious circle Abnormal contractions spasticity
Growth
Retractions
Bone
deformations
vicious circle
1° lesion CNS

3. The Target’s Careful preoperative physical examination
primary contractures
compensatory joint flexion
computerized gait analysis can be useful
sagittal, coronal, and transverse
Bony and soft-tissue surgery remains a common component in the management of ambulatory patients
Shorter periods of immobilization
postoperative gait training

4. Ankle Equinus Deformity
Equinovarus Deformity
Equinovalgus Deformity
Hamstring Spasticity
Hip Flexion Contractures
Adduction Contractures
Hip Subluxation
Rotational Osteotomies

5. Many factors must be considered The goals of: the patient the family
the therapist
the surgeon
Age at the time of surgery
preschool-age child
recurrence
age 7 years
Nonsurgical management
early school age
Johnson DC et al , J Pediatr Orthop 1997

6. Many factors must be considered Gait deterioration Adolescence
Growth spurt
Gain substantial weight
Diplegic and Quadriplegic
Gait worsens
Careful patient selection
Johnson DC et al , J Pediatr Orthop 1997

7. Computerized gait analysis Swing and stance phase
some subjectivity in their interpretation
type of surgery recommended may be altered as 52% to 89% preoperative gait laboratory analysis
multilevel surgery and/or rotational osteotomies
DeLuca et al J Pediatr Orthop 1997
Foot progression angle

8. Ankle Equinus Deformity most common
absence of significant hamstring involvement
knee may “pop” back into recurvatum
feet pull up out of orthoses
Achilles tendon lengthening
Z-shaped lengthening
selective gastrocnemius fascial lengthening
push-off power is better preserved
Recurrence is not uncommon
18% with diplegia
41% with hemiplegia
It remains unresolved
longitudinal growth
more spasticity
Rattey et al J Pediatr Orthop 1993

9. Ankle Equinus Deformity
Z-shaped lengthening

10. Ankle Equinus Deformity
Z-shaped lengthening

11. gastrocnemius fascial lengthening
Ankle Equinus Deformity
gastrocnemius fascial lengthening

12. overlengthening of the gastrocnemius-soleus complex !!!!!!

13. Equinovarus Deformity
Most common in hemiplegia.
Spasticity of the posterior and/or anterior tibialis muscle
Gait analysis or Electromyographic (EMG)
Worsens during ambulation
Tenuta et al J Pediatr Orthop 1993

14. Equinovarus Deformity
tendon transfer or lengthening
Posterior tibialis
split transfer into the peroneus brevis
Anterior tibialis
Rancho procedure
posterior tibialis muscle lengthening
Achilles tendon lengthening
Split anterior tibialis

15. Equinovarus Deformity

16. Equinovarus Deformity

17. Ankle Equinovarus Deformity
Complications of split posterior and anterior tendon transfers
incomplete correction
bony surgery
Overcorrection
younger ages
diplegia rather than hemiplegia
Liggio FJ et al J Pediatr Orthop 2001

18. Equinovarus Deformity
calcaneal osteotomy
triple arthrodesis

19. Equinovalgus Deformity
spastic diplegia or quadriplegia
Spasticity in:
the gastrocnemius-soleus complex
peroneal muscles
If foot is pain free :
Surgery is unnecessary

20. Equinovalgus Deformity
Soft-tissue surgery is ineffective to correct the deformity
lengthening of the lateral column of the calcaneus (Evans ,Mosca)
Forefoot supination
Closing wedge osteotomy of the medial cuneiform
Mosca et al J Bone Joint Surg Am 1995

21. Equinovalgus Deformity
Evans, Mosca

22. Equinovalgus Deformity Calcaneal osteotomy
Rathjen and Mubarak reported favorable results after a sliding calcaneal osteotomy
Rathjen KE, Mubarak J Pediatr Orthop 1998
Arthrodesis
Grice extra-articular subtalar arthrodesis.
Alman BA et al J Pediatr Orthop 1993
It is more difficult to achieve complete correction with triple arthrodesis in the valgus foot than in the equinovarus foot

23. Equinovalgus Deformity
Valgus deformity of the ankle
supramalleolar osteotomy
Hemiepiphysiodesis
External rotation of the tibia
Derotational osteotomy

24. Hamstring Spasticity
frequently observed in ambulatory children
swing phase
patient crouches
popliteal angle
lengthening the hamstring muscle group
gracilis and semitendinosus
Z-lengthened
semimembranosus and biceps femoris
intramuscular lengthening
avoid stretch to the neurovascular bundles
Recurrent crouch often occurs in adolescence

25. Hamstring Spasticity
Stiff-knee gait
cospasticity of the rectus femoris
foot clearance during swing phase
standing to sitting
climb stairs
Gait analysis
EMG of the rectus femoris muscle during swing phase
Treatment
rectus femoris muscle transfer
In to medial hamstrings or sartorius
Simple distal release of the rectus
Ounpuu S et al J Pediatr Orthop 1993

26. Hamstring Spasticity
Decision making for rectus femoris muscle transfers can be difficult
70% of patients will lose some swing-phase knee flexion
only 13% required subsequent rectus transfers
The hamstrings provide stance- phase hip extension
hip extensor weakness
anterior tilt of the pelvis
hip flexion contracture coexists
iliopsoas muscle should be lengthened

27. Hip Flexion Contractures
Common diplegia and quadriplegia
often compensatory
Thomas or Staheli tests
lumbar lordosis
The psoas tendon is identified within the iliacus muscle and selectively sectioned, retracting within the intact iliacus

28. Adduction Contractures
common in patients with diplegia
scissoring
internal hip rotation and flexion at the knee
adductor longus and adductor brevis
Obturator neurectomy
abduction contracture

29. Cerebral Palsy is not only a deformity of foot, knee or hip
It is very important to tackle the child as a whole
Birthday syndrome
Mercer Rang

30. One session multilevel approach
Combination of all soft-tissue procedures
and corrections of bony deformities in one session
Gage JR. Gait analysis: an essential tool in the treatment of cerebral palsy.
Clin Orthop 1993;288:
Gage JR et al. An update on the treatment of gait problems in cerebral palsy.
J Pediatr Orthop B 2001;10:

31. Multilevel surgery concerns ambulatory and cooperating patients to be able to withstand rehabilitation from 4 to 12 months in a specific centre
No mental retardation to cooperate with rehabilitation efforts
Family cooperation is also essential for the success of treatment
Reconsider the treatment plan if the expectations of the family are not consistent with the aims of surgery

32. Hip adductor and psoas releases, femoral derotation osteotomies, …
Multilevel surgery
Hip and femur
Hip adductor and psoas releases, femoral derotation osteotomies, …
Knee and leg
Hamstring lengthening, rectus femoris transfers, patella reaxation, supracondylar extension osteotomy, bone correction of tibial torsion, …
Ankle
Gastrocnemius lengthening, tendon transfers, calcaneal neck lengthening (Evans procedure), hallux valgus treatment, arthrodesis, …

33. The duration of interventions in multilevel surgery is often very long ,To reduce the maximum operating time, the child is operated simultaneously by two surgical teams