Orthopaedic Surgery in spasticity management

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
Oh, quizás
Just a tiny
bit more
(poquito
más)-
Demisiado de
una buena
costa es
estupendio!
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
recurrence25%
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%
good
results
NO NO: TRANSFER WHOLE
TENDON ►► LATE
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 sitsassistant 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 surgerypractical and effective in spastic
diplegia
Iliopsoas
Distal
rectus
femoris
Hamstrings
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?
RISKSSUBLUXATION/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
Age 36 mos.-total body
involved-spastic quad
Over 30%,
surgery
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