SURGICAL CORRECTION FOR DEFORMITY OF THE LOWER EXTREMITIES 振興醫院骨科醫學部 醫師熊永萬 ***

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1 SURGICAL CORRECTION FOR DEFORMITY OF THE LOWER EXTREMITIES 振興醫院骨科醫學部 醫師熊永萬 1

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6 O 型腿的外觀 CAUSES OF EXTREMITY DEFORMITY * TRAUMA * INFECTION * CONGENITAL DISORDER * METABOLIC DISORDER * OTHERS 6

7 CAUSES OF EXTREMITY DEFORMITY * POLIOMYELITIS * CEREBRAL PALSY CLUB FOOT D.M. FOOT GOUTY ARTHRITIS * SEQ. OF N-M DISORDER DYNAMIC DEFORMITY / M. imbalance / Faulty posture / Growth / Abnormal W.B. PERMANENT DEFORMITY GOAL OF TREATMENT * Prevent deformity * Correct deformity * Stabilize flail joints * A.D.L. Independence PREVENTION OF DEFORMITY * Close observation * Close cooperation * M. power balance * Skillful use of supports ** OPTIONS OF TREATMENT * P.T. programs * Brace prevention * M. balance procedures * Skeletal procedures SURGERY?! NO IMPROVEMENT AFTER CONSERVATIVE TREATMENT 7

8 PRE-OP EVALUATION * Weight bearing * Non weight bearing * Walking MUSCLE POWER BALANCE * Spastic muscle release * Tendon transfer * M. transplantation CORRECTIVE OSTEOTOMY ARTHRODESIS ARTHROPLASTY CEREBRAL PALSY POLIOMYELITIS CEREBRAL PALSY Introduction * In the 1860s, William Little described ( Little s disease ) * Stiff & spastic muscles in limbs * Birth complication: Premature Complicated deliveries Oxygen shortage during birth CEREBRAL PALSY * Mental retardation * Visual disturbance * Seizure ( Sigmund Freud in 1897 )? 8

9 WHAT IS CEREBRAL PALSY? WHAT IS CEREBRAL PALSY? Cerebral : Palsy : Brain s two halves Hemispheres Impairs control of body movement * Faulty development or damage to motor areas in the brain * Disrupts the brain s ability to adequately control movement and posture WHAT IS CEREBRAL PALSY? Neither contagious nor inherited * It cannot be cured. ETIOLOGIC FACTORS OF C.P. PRENATAL NATAL POSTNATAL HOW MANY PEOPLE HAVE THIS DISORDER? MEDICATIONS RADIATION HEAVY METALS INFECTIONS BLEEDING TOXEMIA TRAUMA CORD COMPROMISE PLACENTA PREVIA RDS PREMATURITY CRANIAL TRAUMA MULTIPLE BIRTHS SEIZURE ANOXIA JAUDICE MENINGITIS INFARCTION HEMORRHAGE TRAUMA More than 40,000 in Taiwan 500,000 in U.S.A. NUTRITION 9

10 WHAT ARE THE RISK FACTORS? * Breech presentation * Complicated labor & delivery * Low Apgar score * Low B.W. & premature birth * Multiple births * Nervous system malformations * Maternal bleeding or proteinuria late in pregnancy * Maternal hyperthyrodism, mental retardation or seizures * Seizures in newborn WHAT ARE THE DIFFIRENT FROMS? * SPASTIC * ATHETOID * ATAXIC * MIXED SPASTIC C.P. * 70 to 80 % in C.P. * Stiffly & permanently muscle contracted * Scissors gait * Uncontrollable shaking & tremor Scissors Gait ATHETOID ( DYSKINETIC ) C.P. * 10 to 20 % * Uncontrolled, slow, writhing movements * Grimacing or drooling * Movements increase by emotional stress 10

11 ATAXIC C.P. * Rare form ( 5-10 % ) * Sense of balance & depth perception * Poor coordination, wide-based gait * Intension tremor WHAT ARE THE EARLY SIGNS? * Developmental delay * Abnormal muscle tone * Unusual posture * HOW IS C.P. DIAGNOSED? * Moro reflex * Hand preference * C.T, * M.R.I. * Sonogram * E.E.G. * Intelligence tests * D.D.: Genetic disease, Muscle disease Metabolism disease Nervous system tumor HOW IS C.P. MANAGED? C.P. can not be cured but treatment can improve a child s capability. HOW IS C.P. MANAGED? Treatment team for C.P. * Pediatrician: Neurologist, Physiatrist * Orthopedist * Physical therapist * Occupational therapist * Speech & language pathologist * Social worker * Psychologist * Educator * * Family STAGES OF DEFORMITY I. Passively correctable II. Soft tissue fixed deformity but without bony change III. Fixed deformity with bony change 11

12 SURGERY FOR C.P. * Adductors release for hip adductors contraction * Posterior soft tissue release for knee flexion contraction * Lengthening of Achilles tendon for T. equinus * Adductors release for hip adductors contraction * Posterior soft tissue release for knee flexion contraction * Lengthening of Achilles tendon for T. equinus SURGERY FOR C.P. * Muscles or tendons release * Selective dorsal root rhizotomy * Chronic cerebellum stimulation * Stereotaxic thalamotomy * 12

13 GOALS OF PHYSICAL THERAPY * Preventing the weakening or deterioration of muscles ( disuse atrophy ) * Avoiding contraction & abnormal position * Improve child s motor development 13

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16 * * * C.P. SPASTIC TYPE * * Before op. After op. * * * POLIOMYELITIS POLIO.: INFANTILE PARALYSIS VIRAL INFECTION AFFECTED ANTERIOR HORN CELL OF THE SPINAL CORD POLIOMYELITIS * Asymmetric, flaccid, irregular paralysis without sensory involvement over limbs POLIOMYELITIS Affected boys more than girls Lower limbs more than upper limbs or trunk 16

17 POLIOMYELITIS INCIDENCE & ETIOLOGY PARALYTIC POLIOMYELITIS Spinal Polio. PREVENTION Salk vaccine Sabin vaccine Bulbar Polio. Mixed type POLIOMYELITIS * Three antigenically distinct types No cross-immunity between them DIFFERENTIAL DIAGNOSIS * Aseptic menigitis * Guillain- Barre syndrome * Tick bite SURGICAL TREATMENT FOR RESIDURAL PARALYSIS * * * * TENDON LENGTHENING * TENDON TRANSFER * TENODESIS * OSTEOTOMY * ARTHRODESIS * LEG LENGTHENING 17

18 DEFORMITY OF HIP * Flex. contr. * Exten. contr. * Abd. contr. * Add. contr. * Anteversion * Subluxation * Dislocation SURGERY OF HIP * Campbell procedure * P.S.T.R. of hip * Abd. release * Add. release * Lower Yount op. * Open reduction SURGERY FOR FEMUR * Subtrochanter osteotomy * Supracondylar wedge osteotomy * Growth plate arrest * Growth plate stimulation * Leg lengthening 18

19 Before op. DEFORMITY OF KNEE * Flex. contr. * Ext. contr. * Genu varum * Genu valgum * Genu recurvatum After op. Before op. After op. SURGERY FOR KNEE * P.S.T.R. * Release of Quadriceps * Tendon transfer * Correct osteotomy * Arthrodesis * Arthroscopy DEFORMITY OF L/E * Tibia torsion * Bow leg * Leg length discrepancy SURGERY FOR TIBIA * Derotation osteotomy * Wedge osteotomy * Leg lengthening * Growth plate arrest * Growth plate stimulation 19

20 ** ** DEFORMITY OF ANKLE * T. equinus * T. equinovarus * T. cavovarus * T. equinovalgus * T. calcaneus DEFORMITY OF FOOT * Claw toes * Cavus deformity * Claw foot * Dorsal bunion AIM OF OPERATION * Plantigrade plane * Midposition of heel 20

21 S/P L.A.T. & P.F. T. Equino-cavo-varus S/P L.A.T. & P.F. MECHANISM OF T.T. * Replaced paralyzed force * Eliminated dynamic force * Balance dynamic deficit TENDON TRNSFER * > 10 y/o * M. power > grade 4 * Bone procedure first * Midline of foot 21

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25 POST-OP CARE * Circulation * Cast change * P.T. programs * Further treatment GOUTY ARTHRITIS Familial Inborn error of purine metabolism ( HYPERURECEMIA ) * Acute gouty arthritis : peripheral joints * Chronic gouty arthritis: ( tophi ) periarticular & subcutaneous deposits 25

26 GOUTY ARTHRITIS Tophi ( urate salts ) * Renal disease * Uric acid nephrolithiasis GOUTY ARTHRITIS Etiology & Incidence ( uric acid ) * Excessive production * Deficient excretion Infection Alcoholic Dietary discretion Emotional factors Cold exposure Blood dyscrasias Medication Renal disease GOUTY ARTHRITIS PATHOGENESIS Sudden deposition of sodium monourate crystals * Tophi ( urate crystals ) in synovial membrane, bursa, tendon sheath. articular cartilage, subchondral bone * Articular & extra-articular gouty arthritis GOUTY ARTHRITIS TREATMENT * Diet control * Medication * Surgery 26

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29 D.M. FOOT D.M. FOOT 29

30 CLUB FOOT 30

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32 TRAUMA WITH NERVE INJURY 32

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35 膝退化性關節炎 微創單一膝關節置換術 35

36 關節置換術 全膝人工關節置換術 CONCLUSION ( I ) * Function improved * Pain relieved * Alignment of joints 36

37 CONCLUSION ( II ) * Plantigrade gait * Dynamic balance * Brace fitting 振興醫院骨科醫學部 * 熊永萬醫師 THANKS FOR YOUR ATTENTION 37