Orthopaedic Surgery in spasticity management

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					Orthopaedic Surgery in
spasticity management
  Successful approach for
         2003--??
SIMPLIFIED-Simplificado

• Many years of trial and error
• Outcome resulted in consensus
• Objectives:
 -►improve function
 -►prevent structural change
 -►correct structural change
1920’s-1980 We did too much

                     Demisiado de
                     una buena
   Oh, quizás        costa es
                     estupendio!
   Just a tiny
   bit more
   (poquito
   más)-
Improved outcome assessments

• Observational gait analysis with video

• Functional Assessment Questionnaire, FAQ

• Gross Motor Performance Measure

• Evidenced-based outcomes
1980’s to 2003 Less is more

• Improved outcome assessment
 *Instrumented gait analysis *
Spastic Equinus-hemiplegia and
                diplegia
• Sliding Achilles tendon lengthening (Hoke)
    NO Z-lengthenings = calcaneus gait
                      Do not dorsiflex foot
                      beyond 0
                                         Jump
                                         to
                                         crouch


     9 % recurrence
Spastic equinus: Gastrocnemius-soleus calf
                       lengthening

            Vulpius, Baker etc.
                                  Less Calcaneus
                                  risk
                                  More
                                  recurrence-
                                  25%
Spastic equinus-simple
postoperative care
 CAST-WALKING SIX WEEKS
 NO POSTOPERATIVE BRACES,
  ORTHOSES, PHYSIO, OR SPECIAL
  SHOES



 Tennis shoes good enough
Pes varus—hemiplegia
Pes valgus-diplegia
• Varus- hindfoot ►split posterior
 tibial tendon transfer (SPLOTT)
   ☺95%               NO NO: TRANSFER WHOLE
   good               TENDON ►► LATE
   results            VALGUS




  Varus-forefoot ►split anterior tibial tendon
  transfer (SPLATT)
FOOT AND ANKLE
HEMIPLEGIA AND DIPLEGIA
• No gastrocnemius neurectomy
• No translocation of Achilles insertion
• No transfer of posterior tibial or peroneals
  or toe extensors to dorsum of foot (CP is
  not polio!)
• No z-lengthening of Achilles tendon
Spastic hemiplegia--HAND

• LIMITED-SENSORY LOSS-STEROGNOSIS



                             Function
                             depends on
                             visual feedback

          finger tips-eyes
          of the hand
          (Moberg)
Spastic diplegia-pes valgus

• Plantar flexed talus-hind foot equinus




  NO NO transfer of peroneal tendons=late varus
  Defer correction to age 6-7 years
Pes valgus-correction
• Shoes, arch supports, orthotics-USELESS
 Theory of corrective shoes- ‘If you don’t
  see it, it is not there’.
► Surgical correction:
     Subtalar extra-articular arthrodesis
                     or
     Lateral Calcaneal lengthening
            osteotomy (Mosca)
Subtalar extra-articular arthrodesis




                          OR




                             Calcaneal
                             osteotomy of Mosca
KNEE –Flexion deformity

• Spastic hamstrings
    NO transfers (Eggers)
    NO tenotomies
    DO FRACTIONAL LENGTHENINGS
       Semimembranous, semitendinosus,
         biceps femoris
Fractional lengthening hamstrings
     1
                        2           3




    1. Patient supine-surgeon sits-
    assistant extends knee

         2. Midline popliteal incision
              3. Incision in aponeuroses of
              semimembranosus & biceps
                 Z-lengthen semitendinosus
Co-spasticity hamstrings and
quadriceps
Limited knee flexion on swing-less
  than 35 °
Do transfer of distal rectus femoris
  tendon
Hip adduction deformity

No obturator neurectomy
No adductor brevis myotomy
No adductor origin transfer
DO ONLY ADDUCTOR LONGUS
MYOTENOTOMY
HIP Flexion Deformity

                     Iliopsoas-major hip
                     flexor




     Jump position
Hip flexion deformity—discarded
surgical procedures:
• Transfer of tensor fascia femoris
• Ober Yount fasciotomy
• Soutter or Campbell flexor slide
• Transfer of iliopsoas to greater
  trochanter
• Myotomy of anterior gluteus medius
Do iliopsoas tenotomy/lengthening




brim        Tenotomy above pelvic
            brim (Patrick)
            Tenotomy below pelvic
            brim (Sutherland)
            Tenotomy at lesser
            trochanter—NON-WALKERS
Multilevel muscle/tendon surgery-
practical and effective in spastic
diplegia

                  Iliopsoas

Distal
                  Hamstrings
rectus
femoris
                  Gastroc-soleus



          ONE STAGE
Hip internal rotation

              No muscle/tendon
              transfers or
              ‘releases’
               Problem is bone:
               excess femoral
               anterversion
               (torsion)
Correction: derotation
subtrochanteric osteotomy

                     Can defer to
                     age 10+ years



                     No cast
                     Healing-8
                     weeks
Compare: Rhizotomy (SDR) &
Orthopaedic Surgery (OS)-diplegia




 Matched series-2 year follow-up
Shriner’s Hospital-Portland, Oregon & St.
Christopher’s, Philadelphia
                    2003
Subluxation and Dislocation-HIP




          PREVENTION?
RISKS-
SUBLUXATION/DISLOCATOION
• Hemiplegia—NO
• Diplegia walk independent—NO
• Diplegia walk with crutches—Yes
• Total Body Involved-not walking-YES
Prevention=early diagnosis

►AP x-ray HIPS age 30 months—
 every 6 months
                           Migration
                           index
                           Over 30%,
                           surgery
  Age 36 mos.-total body
  involved-spastic quad
Preventative surgery
Iliopsoas tenotomy at lesser
  trochanter for non-walker
If adduction contracture, adductor longus
  myotenotomy
  Non-walker- add
  ant.br.obturator
  neurectomy

√Do before age 4 years
Total body involved (quadr.)

• SCOLIOSIS
   ORTHOSES-INEFFECTIVE
CURVE > 40°--CORRECTION & FUSION
CP curves-often rigid

Anterior disc excision/fusion &
Posterior instrumentation and fusion

                      Arriba Eduardo
                      Luque y
                      gracias

                      Y Deo Gracias
Orthopaedic Surgery in C. P.:
The decision is more important
than the incision.
►Need to examine and re-examine the
 child
►Keep it simple
►Do not do too much

We cannot cure C.P.—a brain disease
Mucho Gracias




           2nd Edition
           2004
           MacKeith Press