10/26/2017. Comprehensive & Coordinated Orthopaedic Management of Children with CP. Objectives. It s all about function. Robert Bruce, MD Sayan De, MD

Transcription

1 Comprehensive & Coordinated Orthopaedic Management of Children with CP Robert Bruce, MD Sayan De, MD Objectives Understand varying levels of intervention are available to optimize function of children with neuromuscular disorders There are no protocols Understand that goals of surgical intervention rely on appropriate medical decision making based on upon a child s comorbidities, function, and commitment by the multidisciplinary team 2 It s all about function But really Tone Distribution of involvement Type of CP Presence of comorbidities 3 1

2 Principles of Surgical Intervention primum non nocere Limit anesthetic risks/complications Minimize perioperative morbidity Maximize function 4 Historical Perspective CP surgery was considered to be birthday surgery Increased number of and longer hospital stays Increased pain Increased exposure to anesthetic events Longer post-operative rehabilitation periods 5 SEMLS Single Event Multi-Level Surgery Benefits Single surgical intervention Bilateral surgery Single rehabilitation Single anesthetic risk Single episode of postoperative pain Allows for smaller finetuning procedures if necessary Risks Potentially increased blood loss Potential increase in intensity of postoperative pain Longer anesthetic time during the single event 6 2

3 SEMLS Requires a multidisciplinary approach PT OT Rehab Neurology Orthotics/Prosthetics Nutrition/GI/Gen Surg assess pre-op needs, post-op plan of care for rehabilitation and conditioning Pre and post-operative tone management Mobility devices ready post-op or during rehabilitation period Help ensure proper wound healing and maintenance of nitrogen balance 7 What does CHOA Offer? Individually tailored plan of care/surgical interventions based upon the child s needs and the expectations of both patient and family. 8 Areas of Orthopaedic Intervention Spine/Chest Wall Hip/Pelvis Knee Foot & Ankle Hand & Upper extremity 9 3

4 Common Conditions Scoliosis Neuromuscular hip dysplasia Muscular spasticity Joint contractures Limb length inequality Planovalgus foot Cavovarus foot Equinus contracture 10 Neuromuscular Hip Dysplasia 11 Neuromuscular Hip Dysplasia 12 4

5 Neuromuscular Hip Dysplasia Dysplasia Subluxated Migration Index Dislocated Acetabulum Shape / Head Coverage Sourcil Tear Drop Femur Anteversion Valgus Progressive Deformity of Femoral Head 13 Neuromuscular Hip Dysplasia 17 Months Tone and growth 26 Months 14 Neuromuscular Hip Dislocation Usually correlates with level of function Controversy of painful vs. non-painful dislocation What are the goals of management? 15 5

6 Treatment Algorithm Prevention Reconstruction Salvage 65 pts followed for minimum 8 years Soft tissue release was effective for long term prevention of hip dislocation in 67% of pts 2 predictors of favorable outcomes Spastic Diplegic Ability to walk 17 Prevention Indications Under age 8 years Hip abduction < 30 deg MI 25-60% Soft tissue lengthening Adductor release Hip flexor release Ambulatory: psoas only Hamstring release If popliteal angle greater than 45 deg 6

7 Neuromuscular Hip Dysplasia Reconstruction Indications Recommended above age 4 years For MI > 60% and dislocated hips Must not have degenerative changes Soft tissue lengthening Femoral osteotomy Varus derotational +/- shortening Pelvic osteotomy Lateral acetabuloplasty PAO if triradiate closed 7

8 pts with CP followed for 7.1 years Success Rates II-94% III-49% IV-27% V-14% 23 Management of Gait Disturbances Equinus Stiff Knee Jump Knee Crouch 24 8

9 My Approach 1. Define pattern of involvement 2. Assess coronal plane deformity 3. Assess sagittal plane deformity 4. Assess axial plane deformity **deformity is not always static** 25 Hemiplegia Typical gait patterns Equinus +/- LLD +/- HS Equinovarus +/- cavus Equinoplanovalgus Stiff Knee 26 CORONAL SAGITTAL AXIAL TREATMENT HIP ADDUCTION LEG LENGTH FLEXION INTERNAL ROTATION 1. ADDUCTOR 2. FEMUR OR 3. PSOAS 4. DEROTATION OSTEOTOMY KNEE VALGUS OR VARUS FLEXION OR EXTENSION DISTAL FEMUR OSTEOTOMY 2. RECTUS TRANSFER 3. HAMSTRING FOOT/AN KLE VARUS VALGUS CAVUS PLANUS ADDUCTION TIBIAL TORSION GS, MEDIAL OSTEOTOMY + ST, SPLPTT, +/- CALC SLIDE, TIB OST ABDUCTION GS, LATERAL OSTEOTOMY, +/- Children s TIBIAL TORSION Healthcare of Atlanta CALC SLIDE, TIB OST 27 9

10 28 29 HIP KNEE FOOT/AN KLE CORONAL SAGITTAL AXIAL TREATMENT ADDUCTION VALGUS OR VARUS VARUS VALGUS FLEXION EXTENSION FLEXION CONTRACTURE & SPASTICITY EXTENSOR LAG TRUE EQUINUS CAVUS APPARENT EQUINUS PLANUS ROTATION ADDUCTION TIBIAL TORSION 1. ADDUCTOR 2. PSOAS 3. HAMSTRING 4. DEROTATION OSTEOTOMY 1. DISTAL FEMUR EXTENSION OSTEOTOMY 2. PATELLAR ADVANCEMENT 3. HAMSTRING GS, MEDIAL OSTEOTOMY + ST, SPLPTT, +/- CALC SLIDE, TIB OST ABDUCTION GS, LATERAL OSTEOTOMY, +/- Children s TIBIAL TORSION Healthcare of Atlanta CALC SLIDE, TIB OST 30 10

11 Specific Indications Distal Femoral Extension Osteotomy plus Patellar Advancement Must be ambulatory!!! Severe crouch gait Knee flexion contracture degrees Extensor Lag >10-20 degrees (images removed due to copyright) 31 Specific Indications When to touch the Hamstring Knee flexion contractures less than 10 degrees Posterior pelvic tilt exists Avoid lateral hamstrings to prevent recurvatum (images removed due to copyright) 32 Percutaneous Tendon Lengthening Technique Indications Patient Selection 33 11

12 Other Considerations 1. Presence of Growth Plates with Growth Remaining Guided Growth Staged Procedure 2. Beware the Hamstring Pelvic tilt Popliteal Angle 3. Beware the Achilles True Equinus vs. Apparent Equinus

13 Summary These are challenging, complex kids Tone determines function Function determines intervention Tone still needs to be managed post-intervention Care of the CP child relies on a strong framework of care by a multidisciplinary team 37 13