Lower Extremity Orthopedic Surgery in Cerebral Palsy

Transcription

1 Lower Extremity Orthopedic Surgery in Cerebral Palsy

2 Hank Chambers, MD San Diego Children s Hospital San Diego, California

3 Indications Fixed contracture Joint dislocations Shoe wear problems Pain Perineal hygiene problems

4 What can Orthopedic Surgery Offer? Lengthen tendons Transfer tendons Relocate joints Rotate bones Fuse joints

5 Principles of Orthopedic Surgery in Cerebral Palsy Single event, multilevel surgery Delay surgery as long as possible (> 6 years) Use spasticity management as adjunct to surgery

6 The Diving Syndrome

7 Timing of Surgery Boyd, Graham et al Eur J Neur 6 (supp 4), 1999

8 Soft tissue contractures Bony abnormalities Morphology Rotation

9 Spine Problems Scoliosis Spondylolisthesis

10 Hip Adduction Deformity Open vs percutaneous lengthening of adductors? Obturator neurectomy Canale and Beaty Operative Pediatric Orthopedics 1991

11 Adductor Lengthening Obturator Neurectomy Canale and Beaty, Operative Pediatric Orthopedics

12 Hip Flexion Deformity Usually caused by contracture of the iliopsoas muscle Sartorius, rectus femoris and tensor fascia femoris muscle can also contribute

13 Treatment of Hip Flexion Contractures Canale and Beaty, Operative Pediatric Orthopedics, 1991

14 Psoas lengthening at the Pelvic Brim

15 Hip Subluxation & Dislocation Acetabular Dysplasia Hip Subluxation

16 Hip Subluxation & Dislocation Indications for Treatment Hip subluxation in any condition Pain Loss of sitting ability

17 Proximal Femoral Varus Derotational Osteotomies Indications for surgery: d valgus d femoral anteversion

18 Acetabular Dysplasia Usually posterior dysplasia Anterior Posterior Mid-superior

19 Treatment of Acetabular Dysplasia Periacetabular Osteotomy, Open Reduction and VDRO

20 San Diego Approach to Hip Dislocation

21

22

23 Salvage Procedure for Hip Dysplasia Interposition arthroplasty

24 Problems at the Knee Crouch gait Jump gait Stiff knee gait Recurvatum gait

25 Crouch Gait Increased hip flexion Increased knee flexion Increased ankle dorsiflexion (calcaneous) Usually iatrogenic

26 Patella Alta

27 Jump Gait In di or hemiplegia Increased hip flexion Increased knee flexion Increased ankle plantar flexion

28 Hamstring Lengthening

29 Stiff Knee Gait Manifest by swing phase knee stiffness Leads to problems of foot clearance Compensatory mechanisms include Hip Circumduction External Rotation Contralateral vaulting

30 Rectus Femoris Transfer

31 Recurvatum Gait Usually iatrogenic Difficult to treat surgically Often need long leg braces (KAFO with the ankle in dorsiflexion)

32 Knee Problems in Adults with Cerebral Palsy Patellofemoral arthritis Patellar malalignment syndrome Meniscal tear Cruciate ligament tears

33 Rotational Abnormalities Lever Arm Syndrome Increased Femoral Anteversion Increased internal or external tibial torsion malignant malalignment syndrome Patellar subluxation/dislocation Foot valgus

34 Treatment Femoral osteotomies Proximal Distal? Gluteus medius transfer Tibial derotational osteotomies Correction of valgus in foot

35 Problems at the Foot & Ankle Equinus Calcaneous Varus Valgus Bunion

36 Treatment Options for Equinus Lengthening of the fascia (recession) Strayer Baker Vulpius Baumann Lengthening of the Tendoachilles

37 Equinus Open Tendoachilles Lengthening Gastrocnemius Recession Strayer or Vulpius

38 Usually iatrogenic Calcaneous

39 Treatment Options for Calcaneous Surgical: Muscle transfer to heel TA, TP, PL, PB, FDL, FHL Heel cord tenodesis Osteotomy of calcaneus (can combine with muscle transfer) Oblique Crescentic

40 The Varus Foot

41 Varus Foot Deformity Usually in hemiplegia Surgical Options include Frost Lengthening of the Posterior Tibialis Muscle Split Posterior Tibialis Tendon Transfer (SPOTT) Split Anterior Tibialis Tendon Transfer (SPLATT)

42 Frost Tibialis Posterior Tendon Lengthening Tibialis Posterior

43 Split Posterior Tibialis Tendon Transfer (SPOTT)

44 Split Anterior Tibialis Tendon Transfer (SPLATT)

45 Valgus Foot Common in diplegia & quadriplegia

46 Treatment Options for the Valgus Foot Peroneus Brevis Tendon Lengthening Calcaneal Lengthening Calcaneal Sliding Osteotomy Subtalar Arthrodesis Triple Arthrodesis

47 Peroneus Brevis Lengthening

48 Subtalar Arthrodesis

49 Subtalar Stapling

50 Evan s Calcaneal Lengthening

51 Sliding Calcaneal Osteotomy

52 Triple Arthrodesis

53 Look for Ankle Valgus

54 Bunion Deformities Dorsal bunion Hallux valgus

55 Treatment Standard bunion procedure Arthrodesis