אתגרים ופתרונות ניתוחיים סביב מפרק הברך בילדי CP ד"ר טלי בקר לאורטופדית ילדים,מרכז שניידר לרפואת ילדים

Transcription

1 אתגרים ופתרונות ניתוחיים סביב מפרק הברך בילדי CP היח' ד"ר טלי בקר לאורטופדית ילדים,מרכז שניידר לרפואת ילדים 1

2 CP- Spectrum of pathology 2

3 Lower Limb problems in CP Spastic Quadriplegia- Hip,Pelvis, Spine Spastic Hemiplegia- Foot and Ankle 3

4 Spastic Diplegia Lower Limb Multilevel Involvement Foot/Ankle- Equinovalgus Knee- Flexion and stiffness Hip- Flexion and Internal Rotation 4

5 5

6 Pathology in CP Abnormal tone Agonist-Antagonist muscle imbalancecospasticity Longitudinal abnormalities- Stance/ Swing Rotational malalignement 6

7 Rotational abnormality Excessive Femoral anteversion External Tibial torsion Patellar instability Subluxation/Dislocation 7

8 Longitudinal abnormalities Knee Flexion Deformity Stance phase abnormalities Jump gait/crouch gait Patella alta Inferior pole fracture Patellofemoral arthritis 8

9 Longitudinal abnormalities (Rodda, Graham et al) 9

10 אתגרים... Dilemma 1 - Why?? 10

11 11 Ground Reaction force

12 12

13 Dilemma 2- Where?? Multilevel involvement! 13

14 Where?? Biarticular muscle contracture 1. Hamstrings 2. Rectus Femoris 3. Gastrocnemius דוגמה- הארכת המסטרינגס תשפר את ישור הברך אך תגרום ל- 14 Anterior pelvic tilt

15 Dilemma 3- How much?? לדוגמה- הארכת אכילס- יכולה לגרום ל- Crouch Selber, Graham et al. - Surgical Dose in CP )2004 מונח שהוצג ע"י CP Academy ( ההתערבות הניתוחית צריכה להתאים לחומרת הבעיה הקלינית 15

16 פתרונות... 16

17 Evaluation (Davids et al.) 17 GMFCS/FAQ

18 Clinical history Complaints- Pain, fatigue, difficulty (not always consistent with other findings..) Level of ambulation GMFCS 18

19 Physical examination Knee flexion deformity predominates Popliteal angle (norm.-25) Differentiate from other deformities (hip, Pelvic Tilt) 19

20 Treatment Gait dysfunction in CP is a combination of weakness and contracture! 1. Muscle strengthening (Isometric) 2. Reduce spasticity (Botulinum A, Dorsal Rhizotomy, Baclofen) 3. Release contracture (Surgery) 20

21 Treatment (Dilemma 4-When?) Spastic muscle contracture Botulinum /Baclofen Fixed muscle contracture Tendon lengthening/transfer Fixed muscle and joint contracture Bony procedures 21

22 Surgery Multilevel- Knee- Correct flexion contracture Hamstrings/ Femur Correct Patella Alta Hip- Release Flexion contracture Correct Anteversion Ankle- Correct equinus 22

23 Hamstring Lengthening Nonambulatory CP- GMFCS IV-V- Improve sitting- Prox. Hamstrings+ Adductor release Ambulatory spastic Diplegia- GMFCS I-II- Improve Walking- Controlled Distal Hamstrings Medial +- Lateral 23

24 Semi-T Transfer (to Add tubercle) Indication- GMFCS- III-IV Severe knee flexion in stance Complication- Hyperextension 24

25 Risks of Hamstrings Lengthening 1. Knee hyperextension 2. Stiff knee in swing (Clearance problems) 3. Anterior pelvic tilt Solutions- Avoid Over lengthening Combine with Rectus release/transfer 25

26 Rectus Femoris Release/Transfer (to Semi-T) Rectus - Active in Swing phase Indication- Decreased knee flexion in swing Clearance problems, toe scuffing GMFCS I-II One stage with Hamstring release/2 nd stage 26

27 27

28 Bony procedures- Supracondylar Extension Osteotomy +femoral shortening 28

29 29 Guided Growth (When?..)

30 30

31 Patellar Tendon shortening Corrects patella alta Usually combined with correction of flexion deformity 31

32 Clinical Case 12y old, spastic diplegia 1) Clinical history- GMFCS 3 Fatigue, anterior knee pain 2) Physical exam.- Hamstrings contracture (pop. Angle -60) 3) Gait analysis- Stiff flexed knee gait pattern Crouch gait EUA- contracture without effect of spasticity Radiographs- Patella alta with fragmentation Treatment goals- 32 Relieve pain Improve walking efficiency

33 Crouch Gait Excessive knee flexion Calcaneus position of ankle during stance Excessive hip flexion Pelvis- Posterior/Neutral/Anterior Short hamstrings- only in patients with posterior pelvic tilt! Hamstrings lengthening increases anterior pelvic tilt 33

34 Plan 1) Muscle strengthening program 2) Surgery- Multilevel Hamstrings release Distal femur extension osteotomy /anterior 8-plates Patellar tendon shortening Consider Semi-T transfer Rectus release/transfer Proximal Iliopsoas release?? 3) Orthosis 34

35 אתגרים... פתרונות...? 35

36 תודה רבה... 36