Cerebral Palsy Surgical Treatment 을지의대김하용

Transcription

1 Cerebral Palsy Surgical Treatment 을지의대김하용

2 In the Past ( 시행착오의시기 ) RP surgery 에서 CP surgery 로젂환하면서 Trial and errors 를겪었다. 걷던아이가수술후못걷는다. Period of adductor tenotomy and TAL 이시기의특징 CP 는수술의결과가 RP 보다나쁘다. Mechanical deformity 의 Staged surgery Birthday syndrome and Diving syndrome Some deterioration due to Wrong focusing (e.g. Pseudo-scissoring) Unnecessary surgery Over-lengthening/ Neurectomy

3 Diving Syndrome Initial TAL DHR Psoas

4 Results of Surgical Treatment Long periods of immobilization after each intervention Childhood is a series of surgeries & recoveries.

5 Over-lengthening of Adductors Overlengthening of Adductors & Iatrogenic after obt. N. neurectomy Weak adductors & ugly unstable gait

6 Lessons from T & E (1) Neurectomy 는더심한, 혹은예측할수없는변형을초래한다. Power generating M 은보행에중요하다. 1Achilles, 2Psoas + Adductors 3Hamstrings 원위부근육 (distal muscles) 일수록이환정도가더심하다. 2 관젃근육 (Two joint muscles) 일수록병적이다. Psoas, Rectus femoris, Gastrocnemius

7 Lessons from T & E (2) Lever arm disease 대체로 bony deformities 이다. Femoral anteversion, Malrotation syndrome Flatfoot Hip subluxation 교정이쉽다. 교정후결과가좋다. 보행의에너지효율을높인다.

8 그기간동안새로운발전이있었다 Gait Analysis New Tools for control the spasticity Botox, SDR, ITBP Adaptive devices for Non-ambulators Pain & Hygiene Hand and UE surgery

9 With this progress Doctors (Surgeons) can do something for CP patients. It is NOT CURE, BUT Quality of Life

10 Role of Gait Analysis

11 Role of Gait Analysis 3-D GAIT ANALYSIS 시술 ( 수술 ) 젂 정량적평가 치료방법의변화 Intervention 시술 ( 수술 ) 후 정량적평가 시술 ( 수술 ) 의 결과에대하여 객관적이고정량적인평가

12 Role of Gait analysis in CP 여러개의서로링크된관젃 (multiple interlink joint) 상태의평가가가능하며 일차, 2 차변형및 3 차보상기젂을감별하도록해주며 결과적으로 SEMLS (Single Event multilevel surgery) 가가능해졌다

13 Surgical Principles

14 Two main Principles for CP surgery SEMLS Single-event Multilevel surgery James Gage SMILE Sequential Multiple Intervention for Lower Extremity Michael Sussman

15 SEMLS Single-event Multilevel surgery James Gage

16 SEMLS CP 아이들은복잡한보행의 pathology 로여러다른수술적 procedures 가필요하다. 과거에는이수술들을여러번나누어해서 "birthday syndrome 같은일이발생했지만, 보행분석검사 (gait analysis) 로보행의 pathology 를여러 level 에걸쳐, 3 차원적으로파악할수있게되어, 앆젂하게여러부위를동시에수술하게되었다 (single event multilevel surgery or SEMLS).

17 Indication of Surgery Spastic type Mild dyskinetic or mixed Not indicated for ataxic form

18 One Stage Surgery Ideal age: 5-7 yrs 5세가넘으면, 보행이성숙되고 ( 평가가용이 ) 수술후재발률이낮아지며 재활이쉽다 이시기의수술로써 bony deformity 같은변형의짂행을예방할수있다.

19 SINS! James Gage Gait Analysis Workshop in Connecticut 수술은비가역적시술 : 잘못되면수술젂보다훨씬기능을잃을수있다! (There is no orthopedic problems in CP that cannot be made worse by surgery! ) 잘못의유형 (The Sin ) 하지말아야할것을한것 (Sins of commission) 해야할것을하지않은것 (Sins of omission)

20 하지말아야할것을한잘못 (Sins of Commission) Unbalancing muscles Staged surgery/ Diving syndrome Cutting away power generators Hip extensor in loading response Ankle plantar flexor at push-off Hip flexor-adductor in early swing Neurectomies in any form Most tendon transfers

21 해야할것을하지않은잘못 (Sins of Omission) Failure to correct lever arm dysfunction Pes valgus/varus External tibial torsion Femoral anteversion Hip subluxation Abductor moment-arm insufficiency

22 Gait without hip flexor

23 SIN 1: Tendo Achilles over-lengthening Results in crouch gait Triceps surae is over-weakened Soleus can no longer restrain tibia during second rocker Video-clip by JY chung

24 Sin 2: Tendon Transfers in Foot Complete muscle transfers in the foot in CP are dangerous PB Tf hindfoot varus TP Tf hindfoot valgus PL Tf dorsal bunion a/o forefoot supination Split transfers work well and are unlikely to produce iatrogenic problems.

25 Sin3:Over-lengthened Hamstrings Hamstring: Powerful Hip extensor Produces lordotic, stiff knee gait Loss of posterior pelvic support intractable lordosis Permanent loss of hip extensor strength in first half of stance Marked dominance of rectus femoris at the knee No real solution exist for this problem Psoas lengthening, Rectus transfer??? Abdominal strengthening???

26 SMILE (SEQUENTIAL MULTI-LEVEL INTERVENTIONS IN THE LOWER EXTREMITY AS NEEDED) Michael Sussman Lecture at AACPDM

27 Sequential TIMING OF SURGERY IS DETERMINED BY FUNCTIONAL NEED - NOT by PATIENT AGE Functional skills 은아이가발육하면서계속적으로얻어짂다. DMS 가짂행하는것을방해하는변형이제거되지않는다면, 그아이는더이상 Functional skills 의발젂을짂행시키지못할수있다. 5 세이젂이어도필요하면?( 수술 ) 을해라! (Such as adductor/ Achilles) PROPER ORTHOPAEDIC SURGERY FACILITATES THE DEVELOPMENT OF FUNCTIONAL MOTOR SKILLS

28 SURGICAL TIMING Surgery should be done a la carte rather than waiting until a certain age and doing everything at once (single event multi level surgery) hospitalization is short mobilization is rapid SEMLS is not easy to rehab patients are rapidly returned to their normal lifestyle SEQUENTIAL MULTI-LEVEL INTERVENTIONS IN THE LOWER EXTREMITYAS NEEDED

29 Peripheral pathology

30 Abnormalities Due to CNS Damage Primary abnormality Secondary abnormality

31 Primary Abnormalities -direct pph manifestations d/t CNS damage Abnormal muscle tone - Spasticity Muscle imbalance Deficient equilibrium/coordination Loss of selective muscle control Dependence on primitive reflex pattern Weakness

32 Development of 2 o abnormalities Primary abnormalities Spasticity & Imbalance between agon./antago. Strong agonist- no stretching - no growth Weak antagonist - overstretching -overgrowth + Time & skeletal growth Dynamic Shortening Muscle contracture + bony deformity Static Shortening & Deformity

33 Treatment Modalities for Primary Abnormalities Abnormal muscle tone - Spasticity: NS, Drugs, PT, OS Muscle imbalance: PT, Inj. Med, OS Deficient equilibrium/coordination: PT, Orthotics Loss of selective muscle control: PT, (Time) Dependence on primitive reflex pattern: PT,? Weakness: PT, Orthotics

34 Treatment Modalities for Secondary Abnormalities Muscle contractures: OS Bony deformities: OS Joint deformities: OS, Orthotics

35 Goal of Surgery to improve function prevent deformity decrease pain from joint dislocation or subluxation prevent skin pressure areas improve sitting position improve cosmesis and hygiene to facilitate orthotic management

36 Goal and GMFCS level GMFCS II and III patients Surgeries designed to improve ambulation GMFCS IV and V. to permit pain-free sitting To reduce movement problems (mixed dystonia and mixed motor patterns)

37 J Pediatr Orthop Dec;29(8): The gross motor function classification system for cerebral palsy and single-event multilevel surgery: is there a relationship between level of function and intervention over time? Godwin EM, Spero CR, Nof L, Rosenthal RR, Echternach JL. Department of Orthopaedics and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA. Conclusion: The majority of children in this study showed changes in gross motor function classification as reflected by lower GMFCS scores after SEMLS intervention. We also found that changes were maintained over a period of 5 years.

38 4 types of orthopedic surgery Musculotendinous or tendon lengthening Tendon transfers Osteotomies Arthrodesis [NB]Peripheral neurectomy long-term outcome is not predictable and is generally not performed.

39 Lengthening of spastic Tendon Z-plasty, Aponeurotic lengthening, recession 구축 (contracture) 을교정 근력의저하 Musculotendinous unit 의 tension 을감소시킨다 Tone 과 spasticity 의감소

40 Tendon transfer 경직이있는 deforming tendon 을기능적인위치로옮겨주어서관젃의 balance 를유지하거나, 특별한기능을하도록한다. UE: green and banks(fcu ECRB) LE Rectus transfer for stiff knee gait split transfer of tibialis anterior or tibialis posterior muscle for spastic hemiplegia and a varus foot deformity

41 Osteotomy For many lever-arm disease The use of osteotomies, including shortening osteotomies, has decreased the use of tendon lengthening and is preferred when possible. rotational abnormalities (increased femoral anteversion and internal or external tibial torsion) Hip subluxation or dislocation multiple foot and ankle deformities

42 Arthrodesis Fusion of the thumb and wrist Arthrodesis of the first metatarsophalangeal joint (Hallux valgus) Extra-articular fusion of Subtalar joint (Pea planovalgus (vs. Calcaneal lengthening)) Spine fusion (scoliosis)

43 CP Surgery : Cases

44 Case 1 Equinovarus

45 Equinovarus Common in Spastic hemiplegia Cause: spasticity of tibialis posterior and gastrocnemius-soleus muscle complex (± Spasticity of Tibialis anterior)

46 Surgical Evaluations [1. Muscle] What is the dynamic deforming force: T.P. a/o T.A.? [2. Bone] Are there any bony deformities?

47 Surgical Evaluation(1): Selection of TP or TA? (KW Dabney and F Miller, OKU, 2006) Varus in stance phase + T.P. with no fixed contracture and constant activity SPOTT Varus in swing phase + T.A. with constant activity or throughout most of stance phase Constant activity of TA and TP SPLATT SPLATT + TP lengthening

48 T.P split transfer(spott)

49 T.A split transfer(splatt)

50 Surgical Evaluation(2): Is the deformity passively correctable? Heel Varus Coleman Block test Coleman test (+, Heel varus corrected) with plantar flexed 1 st MT Coleman test(-) with plantar flexed 1 st MT MT osteotomy Dwyer + MT osteotomy

51 Summary Passively correctable Correction of Equinus + TP aponeurotic lengthening TP split transfer(spott) TA split transfer(splatt) Bony deformity Dwyer osteotomy MOLC osteotomy 1 st metatarsal extension osteotomy Triple osteotomy Triple arthrodesis

52 Case

53 Triple Osteotomy (+ Metatarsal extension osteotomy Quadruple osteotomy) Rigid and Severe equinovarus

54 Case 2. Pes Planovalgus

55 Common Cause Common in spastic diplegia and quadriplegia Equinus contracture + increasing GRF (BWt) (+ lack of medial sling (Weakness of tibialis posterior)) Restriction of 2 nd rocker midfoot break - Dorsal subluxation of navicular - Lateral rotation of calcaneus -Talar head falling plantar-medially Relative or actual shortening of lateral column

56 Clinical Feature Increased foot pressure on the medial side of the foot, especially over the talar head (pedobarograph) ±Sometimes pain over this area ±Hallux valgus deformity (d/t dragging) Flexible and decreased lever arm of the foot during the push-off phase Diminished plantar flexion-knee extension couple

57 X-ray Standing AP and Lateral view of the foot and ankle 3. Midfoot abduction 3. Midfoot Breakage 1. Equinus 2. Heel Valgus Dorsolateral subluxation of navicular

58 Treatment Dynamic spasticity AFO Younger children with mild to moderate deformities Older children with more severe deformity Equinus correction and 1. Calcaneal lengthening Equinus correction and 2. Subtalar arthrodesis 3. Calcaneal osteotomy

59 Inserted bone

60 Preop Postop

61 X-ray findings Preop Postop

62 Case 3. In-toeing

63 Scissoring?

64 Right Limb of Patient Norm of Right Limb

65 Post-FDO, psoas, DHR

66 Femoral anteversion Hip, foot Internally rotated Pelvis Compensatory external rotation Excessive anterior tilt Gait Short step or stride length OP Indication If insufficient external rotation to maintain foot progression angle normal anteversion > 45 0 internal rotation > 65 0 external rotation < 20 0

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68 Case 4 M/5 CP spastic diplegia (R<L) Right: mild equinus Left: Jumping gait with femoral torsion

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70 Problems Surgery Right Mild equinus (Strayer) Left Foot: equinovarus Strayer, TA spl Tf, TP aponeurotic lengthening Stiff knee gait DHR & Rectus transfer In-toeing gait Dist FDO Flexed hip Psoas lengthening over the pelvic brim

71 Postoperative Gait (POP 1yr)

72 Anatomic zones of the gastrocsoleus complex. The gastrocsoleus complex has three discrete anatomic zones, which are illustrated here with the corresponding surgical procedures associated with each zone (J Child Orthop August; 4(4): Surgical correction of equinus deformity in children with cerebral palsy: a systematic review Benjamin J. Shore, Nathan White, and H. Kerr Graham)

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74 Results of Operation (Graham HK. (JBJS-B 2001)) At follow-up, 42% had satisfactory calf length, 22% had recurrent equinus and 36% calcaneus. Risk factors' for calcaneus Severity of involvement, female gender, age at operation of less than 8 years and percutaneous lengthening of tendo Achillis Risk factors of recurrent equinus Hemiplegia, male gender, and an aponeurotic muscle lengthening Percutaneous lengthening of tendo Achillis in diplegia was the least predictable, only 38% having a satisfactory outcome.

75 Postop 5yrs Complains in-toeing gait

76 Rotational profile IR 40/40 ER 45/45 TFA 0/0 Foot MA(-/-) FPA (internal 10/10) In-toeing 의원인과치료는?

77 THANK YOU Oregon coast

78 How can we avoid this sins? Primum Non Nocere! (Do no harm!) If you don t understand the problem Don t try to fix it. Doing nothing is better than doing the wrong thing! S E M L S Take responsibility and learn from your mistakes. Formulate realistic and logical goals Orthopedic surgery cannot improve Selective motor control and Balance(?).

79 Modification of Surgery To preserve the Power generator muscles Heel cord lengthening in zone 2,3 than zone 1 DHR mod. Psoas lengthening over the pelvic brim

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81 Timing of surgery >5 yrs : Independent walker (SEMLS) <5yrs : To promote DMS Surgery(TAL, Adductor) / Any time other intervention Hip subluxation Specific functional needs, e.g. sitting balance