Why Would Your Child Need to See Me?

Transcription

1 Why Would Your Child Need to See Me? Deborah M Eastwood Great Ormond St Hospital for Children, London The Royal National Orthopaedic Hospital, UK Disclosures I am an orthopaedic surgeon and I do operate I heal with steel but there are limits! Bears of Little Brain? 1

2 Disclosures Like you I believe in a holistic approach to the patient But perhaps unlike you... I know that all operations cause harm Treatment should alter the natural history for the better Not just make people different So I tend towards a conservative approach As a surgeon what can I do? Improve function? Reduce pain? Alter appearance? Change an x ray? Make someone s life easier? Prevent deterioration? All (or none!) of the above? 2

3 As a surgeon what can I do? Soft tissues Release tight tissues Lengthen /Transfer muscles Weakens but more effective Bones Realign (and strengthen?) Joints Relocate (replace), excise or fuse Lever Arms Define the Problem? Each child is different 3

4 Define the Problem Cerebral palsy A group of non progressive disorders Impairment of motor function and posture Associated problems Perinatal insult Its black and white... Too little of the white Effects of the insult are progressive Define the Problem Alteration in tone Low tone High tone Mixed : some high/some low Variable : good times/ bad times Lack of control 4

5 GMFCS: Gross Motor Function Classification Scale I IV / V III GMFCS Gross Motor Functional Classification Scale GMFCS I Hips are good IV / V GMFCS V Hips are bad Most but not all 5

6 GMFM : Gross motor function measure Measures change over time and/or with treatment Point C 50% of children can walk 10 steps Remember The severity of the condition Life expectancy Can be good But Significant reduction With Significant disability 6

7 Cerebral Palsy Brain lesion Nutrition POSNZ 2016 Cognitive involvement Motor impairments Respiratory & GIT involvement Bone Health Orthopaedic disability Spasticity Loss of motor power Loss of selectivity Loss of fine motor control Tight, short muscles Abnormal pulls on growing bone Static brain lesion Muscle imbalance Flexible deformities Contracture Fixed bony deformities Normal muscle growth needs a regular stretch of relaxed muscle under physiological load 7

8 The Two Joint Muscles Hamstrings As they contract Extend the hip Flex the knee Classic problems Walking Wheelchair position The Two Joint Muscles Gastrocnemius As it contracts Flex the knee Flex the ankle Classic Problems Walking Foot and ankle position Foot wear 8

9 Look Up and Down! Flexed knees & Equinus heels The Two Joint Muscles Unilateral (Hemi) Bilateral (Diplegia) Psoas, hamstrings, rectus femoris & gastrosoleus 9

10 Contracture Dynamic or Fixed Deformity Stiff or Supple? Define the Problem Is it a contracture of Muscle Tendon unit Or Joints Or Both? And is there any bony deformity? 10

11 Define the Problem Is it a contracture of Muscle Tendon unit Or Joints Or Both? Muscle or Joint Contracture? Or Joint deformity? 11

12 Aims of Soft Tissue Surgery Working as part of a team Maintain muscle /tendon length Or regain length and then maintain it Rebalance muscle forces to stabilise joints To improve position and hence function Indications for Surgery When conservative measures are 1. Ineffective 2. Impractical Failure to obtain Failure to maintain A corrected foot A 12

13 Equinus Contracture Options Fixed equinus of any degree? Release a calf muscle (many ways) Obtain a plantigrade foot But Don t get too much dorsiflexion When?? Plaster cast and then an AFO Joint Release Usually when muscle releases alone are insufficient Contracture long standing 13

14 Tendon Transfers: to improve function Equinovarus Foot (the hemi foot!) No fixed deformity So if there is deformity, correct that first! Examples: Tibialis posterior at the ankle Pronator teres at the forearm Must be a strong muscle to transfer MRC 4/5 It will be weaker when you move it Will it be working against gravity? Break the Bone and Realign The Flatfoot Equinus disguised as valgus Gastrosoleus lengthening Correct deformity Osteotomy /Fusion Calcaneal lengthening Subtalar /Triple fusion Tibial derotation? 14

15 Knee Flexion Contractures Options FFD > degrees? Hamstring tightness Fractional lengthening avoid sciatic nerve injury overlengthening is BAD Knee Flexion Contractures Acute correction? Distal femoral extension osteotomy FFD > 20 degrees Previous lengthening? With Patella tendon surgery Or Gradual correction Guided growth Sciatic nerve Quads inhibition? 15

16 Correction of Fixed Deformity At plate insertion At plate removal Takes Time Have you got time? Is the patient deteriorating rapidly Hip Flexion Contracture Options FFD > degrees Psoas release In the groin? Rectus Femoris Duncan Ely Test 16

17 Hip Adduction Contracture Loss of abduction in flexion and/or extension < degrees abduction each side? Options Adductor longus / gracilis release? Internal Rotation Contracture Is the leg falling in or is it being pulled in Femoral torsion A twist on the thigh bone Derotation osteotomy 17

18 TBI Child Hips & the Spine And also Knees & Feet Arms Hip joint stability Pelvic obliquity Spinal alignment Is Hip Dislocation Predictable? CPUP Score = CPIPS in the UK Young age High GMFCS level Migration percentage Changing clinical picture High vs Low risk hips Hagglund G et al 2015 >170 0 >40% 18

19 Is Hip Dislocation Preventable? Yes But At what cost? Surgery Many need repeat/further surgery Complication rate?? Hagglund G, BJJ 2014 Is Hip Dislocation Preventable? With surveillance programmes These are Never Events But at what surgical and emotional cost? 19

20 CPIPS and the Radiograph Migration percentage The Migration Percentage Which X ray represents the true picture? What about the other hip? Windsweep Index The Abducted Hip 20

21 Consider The Timeline Days, weeks, months or years!!! To Keep the Hip in Tone Management Positioning Stretching Neuromuscular blockade Surgery Soft tissue release if appropriate Femoral +/ pelvic osteotomy Start surgery when the MP >33-40% and progressing?? 21

22 The Patient Hip Reconstruction: Big Surgery Is it feasible?? Open reduction of the joint Femoral osteotomy Pelvic osteotomy And The other side... same day? Botulinum toxin? Usually no plaster casts Better than proximal femoral excision? 22

23 Consider The Extended Timeline Years?.. Not many?? Proximal Femoral Excision: A floppy hip For sitting posture, pain relief, perineal care 23

24 The Spine Scoliosis Lordosis Fusion to the sacrum?? where does the spasm go?? Reveals hip pathology Causes hip pathology So... What should I do? Why And To whom?? What is the specific problem? 24

25 What is our treatment aim? Who do we do it to? The Hemiplegic Patient (Unilat) The Walking Diplegic ( Bilat) The Barely walking Diplegic (Bilat) G M F M The Total Body Involvement Patient 25

26 What stage are we at? Gait Improvement Surgery? Have to be able to walk With Good prognosis for continued walking In the medium term? Or Can you kick start walking Improve weight bearing transfers 26

27 Prevention Programmes? Hips Subluxation/dislocation Spines Early surgery Knees For standing frame use Feet To maintain standing ability The Walking Diplegic Who/what is controlling the strings? He needs to keep upright Don t make it harder for him Don t weaken him too much The SDR problem Have you got the right support Physio and orthotics? Has he? 27

28 Birthday Surgery vs SEMLS Timing is everything Little and often? But only when its necessary Is it limiting function SEMLS (often bilateral) 3 steps back to go 1 step forward? The Barely Walking Child and therefore the TBI child For comfortable balanced sitting & Independent transfers. A straight spine and horizontal pelvis Stable and painless hip Hip flexion: 30 o to 90 o Knee flexion: 20 o to 90 o Plantigrade feet 28

29 Pre operative Planning Anticipate Pain, upset and spasm Constipation and reflux Splints etc must be comfortable Pain Can tone management be improved? Teamwork is essential Spasm Upset Botulinum Toxin A Injections Exact Technique? Still not well defined Dose Dilution / Volume 1 Site or more? with GA, LA, sedation? 29

30 Spasticity (different from dystonia) Definition: a velocity dependant increase in tonic stretch reflexes Loss of inhibition Hyper excitability Loss of inhibition agonist antagonist SDR: Decrease the Input x agonist antagonist Reduce the output 30

31 What are you hoping to achieve? A reduction in muscle tone To facilitate motor development and/or maximise function Measured how?? SDR : NHS Criteria (July 2018) For spasticity, predominantly legs, functioning at GMFCS II/III 1. age Dynamic spasticity in legs, affecting function and mobility No dystonia 3. MRI: typical CP changes only ie PVL / prematurity Not basal ganglia, cerebellum 4. No other explanation 5. Mild to mod. weakness; can maintain anti gravity postures 31

32 SDR : Criteria for NHS Commissioning For spasticity, predominantly legs, functioning at GMFCS II/III 6. No significant scoliosis 7. Hip migration percentage <40% Implication is that you should fix the hips before the SDR But What about the knees /ankles etc SDR: Evaluation Data collection GMFCS Tone : Modified Ashworth Scale Strength: Modified Oxford Score Selectivity: Boyd and Graham Joint ROM GMFM 3 d Gait analysis (pre op and at 2y) CP QoL measure Hip and spine x rays KiTEC Interim Analysis (CtE) Improvements in motor function GMFM MCID not yet defined Improved QoL Pain (small reduction) Feelings about functioning Participation and physical health Emotional wellbeing and self esteem Family health Evidence review: clinical significance? 32

33 SDR Treats tone Not Contractures Orthopaedic surgery is often still needed At time of SDR??? Usually later SDR Like all surgery SDR is an irreversible game changer For some kids... it s a miracle For many it helps For some it harms Comfort vs Function 33

34 When your child comes to see me I have 20 mins (or 10) To get to know the child and their family Understand their goals Examine the patient Check investigations Try and devise a plan Or arrange a review! What I would like from you A detailed report Clear idea of their current functional level Changes over time and response to previous treatments Parents aims The questions you want answering I am not inherently a monitoring service.. but I can advise We are team players sharing the delivery of care 34

35 Most of us Can and do look after the whole patient At least to start off with Spinal bracing can be instigated by a general orthopaedic surgeon We can do upper limb as well as lower limb problems Timing is Everything We need to pick The right operation, at the right time, for the right reasons in the right patient with the right family and the right resources (both medical and non medical) with the right team to support us to get the right result! 35