אתגרים ופתרונות ניתוחיים סביב מפרק הברך בילדי CP היח' ד"ר טלי בקר לאורטופדית ילדים,מרכז שניידר לרפואת ילדים 1
CP- Spectrum of pathology 2
Lower Limb problems in CP Spastic Quadriplegia- Hip,Pelvis, Spine Spastic Hemiplegia- Foot and Ankle 3
Spastic Diplegia Lower Limb Multilevel Involvement Foot/Ankle- Equinovalgus Knee- Flexion and stiffness Hip- Flexion and Internal Rotation 4
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Pathology in CP Abnormal tone Agonist-Antagonist muscle imbalancecospasticity Longitudinal abnormalities- Stance/ Swing Rotational malalignement 6
Rotational abnormality Excessive Femoral anteversion External Tibial torsion Patellar instability Subluxation/Dislocation 7
Longitudinal abnormalities Knee Flexion Deformity Stance phase abnormalities Jump gait/crouch gait Patella alta Inferior pole fracture Patellofemoral arthritis 8
Longitudinal abnormalities (Rodda, Graham et al) 9
אתגרים... Dilemma 1 - Why?? 10
11 Ground Reaction force
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Dilemma 2- Where?? Multilevel involvement! 13
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
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
פתרונות... 16
Evaluation (Davids et al.) 17 GMFCS/FAQ
Clinical history Complaints- Pain, fatigue, difficulty (not always consistent with other findings..) Level of ambulation GMFCS 18
Physical examination Knee flexion deformity predominates Popliteal angle (norm.-25) Differentiate from other deformities (hip, Pelvic Tilt) 19
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
Treatment (Dilemma 4-When?) Spastic muscle contracture Botulinum /Baclofen Fixed muscle contracture Tendon lengthening/transfer Fixed muscle and joint contracture Bony procedures 21
Surgery Multilevel- Knee- Correct flexion contracture Hamstrings/ Femur Correct Patella Alta Hip- Release Flexion contracture Correct Anteversion Ankle- Correct equinus 22
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
Semi-T Transfer (to Add tubercle) Indication- GMFCS- III-IV Severe knee flexion in stance Complication- Hyperextension 24
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
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
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Bony procedures- Supracondylar Extension Osteotomy +femoral shortening 28
29 Guided Growth (When?..)
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Patellar Tendon shortening Corrects patella alta Usually combined with correction of flexion deformity 31
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
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
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
אתגרים... פתרונות...? 35
תודה רבה... 36