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1 SURGICAL TREATMENT OF CEREBRAL PALSY G. A. POLLOCK, EDINBURGH, SCOTLAND The surgical treatment of cerebral palsy began with Little (1862). He believed and taught that the best method of correcting an equinus deformity in a spastic child was by operationa belief that was founded upon the successful subcutaneous lengthening of his own heel cord. The early successes that followed tendon lengthening led to a widespread but too uncritical acceptance of surgical treatment as the method of choice in cerebral palsy. The late bad results that inevitably followed such an approach brought discredit for a time on all surgical procedures in the treatment of these patients. In recent years a fuller appreciation of the whole problem of cerebral palsy by the surgeon and an equally clear recognition of the limitations of his art in its treatment have done much to re-establish confidence. Orthopaedic surgery is not required in every case of cerebral palsy : it forms only one facet of the treatment problem. Nevertheless, experience has shown that in selected cases greater benefit can be conferred by wise surgery and in a shorter time than by any other method. To increase the chances ofsurgical success it is desirable that: 1) the diagnosis be accurate; 2) the patient be observed and studied over a period before operation is advised ; 3) care be exercised in selecting the appropriate operation ; 4) the patient be moderately intelligent, cooperative, and eager to improve ; and 5) the effects likely to follow operation be first assessed by certain pre-operative tests. Accurate diagnosis is essential, because all forms of cerebral palsy do not respond equally well to orthopaedic measures. It is generally accepted that in the athetoid patient muscle transfer and tenotomy are liable to be followed by recurrence of the deformity or by similar tensions and uncontrolled movements in the muscles that remain-an understandable development if a lack of central integration of movement is the basic cause of the condition. Baker (1956), however, has reported satisfactory results in the athetoid after surgery. In ataxia, rigidity and tremors, little if any benefit has followed surgical treatment. It is in the correction of the fixed deformities of the spastic form of cerebral palsy that surgery is particularly suitable. SELECTION OF PATIENTS Each candidate for surgical treatment should be selected with care after individual study and observation over a period ofmonths, during which conservative care is maintained. A snap decision to operate is as fatal to success as a tramcar diagnosis. In the selection of the appropriate orthopaedic operation special consideration must be given to the requirements of the individual patient, it being recognised that an absence of any urge to improve on the part of the patient may ruin what might otherwise have been a satisfactory operation. The possession of a degree of intelligence sufficient to enable the patient to cooperate in his treatment after operation is only a reasonable prerequisite to surgery, and in those patients whose surgical correction involves the upper limb an even higher intelligence is desirable. O Connor s recent work (1954, 1955) in the training of imbeciles (intelligence quotient 35) to perform certain functions suggests that the prolongation of training over a longer time, and with a Job-like patience on the part of the instructor, may produce results even when intelligence is of a low order. If a degree of improvement comparable to that provided by operation can be obtained by conservative measures, there can be very few cases in which surgery is justifiable unless time is a factor of prime importance. 68 THE JOURNAL OF BONE AND JOINT SURGERY

2 SURGICAL TREATMENT OF CEREBRAL PALSY 69 Finally, a trial run should be employed whenever possible to determine the probable result of the operation and the emotional reactions of the patient to it. Fixation of a knee, wrist or foot in plaster before operation may provide valuable information both to the surgeon and to the patient before an irrevocable step such as an arthrodesis is taken. Infiltration of muscles or nerves with a local anaesthetic to reduce muscle spasm may demonstrate the presence or absence of an underlying fixed contracture, and so indicate the need, or otherwise, for surgical correction. FIG. 1 FIG. 3 Case 1-Bilateral subluxation of hips. Figure 1-The patient before operation. Figure 2-Radiograph before operation. Figure 3-After treatment by open reduction on the left and Lorenz osteotomy on the right. Patient was mobile in brace two years after operation. Full consideration of these factors may favour surgery rather than conservative measures, but before the final decision is made one other question must be answered: Is the operation likely to be of functional benefit to the patient or to his relatives? There is no surgical justification for straightening the legs of a chair-bound individual, or, for that matter, in condoning months or years of corrective exercises in the hope, often forlorn, of achieving such a result: the time could be used to much better purpose in providing education or in developing self-help activities. There is every justification for correcting a gross flexionadduction deformity of the lower limbs in a bedridden patient for purposes of nursing or hygiene (Figs. I to 3). It must be realised by the patient and by his guardians that no operation automatically confers an increased ability to perform: the object of the operation is primarily to facilitate training and rehabilitation, to make the tasks of the occupational therapist, physiotherapist and teacher simpler. In the absence of a desire to progress, surgery can confer no benefit and may even do harm. VOL. 44 B, NO. 1, FEBRUARY 1962

3 70 G. A. POLLOCK It is for this reason that observation over months is so important a prerequisite to surgery, and the urge to do so essential a factor in success. This urge to achieve physical improvement is not of necessity dependent on a high level of intelligence and, in some cases, may be present in its comparative absence. The views expressed in this paper are culled from my own experience, as the result of a review of 466 operations performed by my colleagues and myself and reviewed by me over a period of ten years (sixty-six upper limb; 400 lower limb). FIG. 4 Case 2-Wrist fusion in left spastic hemiplegia with satisfactory function. The patient is now a telephone operator. DEFORMITIES OF THE UPPER LIMB The disabilities of the upper limb from cerebral palsy vary in degree from a mere clumsiness of the hand to complete loss of function, from a mild incoordination of digital movement at one end of the scale to the uncontrollable writhings of the dystonic athetoid at the other. A diminution of mobility due to rigidity, or its total abolition from muscle paralysis, is much less frequently found. A greater degree of neuromuscular coordination is required to thread a needle or to fasten small buttons than is demanded for such mass movements as standing or walking. It follows, therefore, when function forms the yardstick of the success or failure of an operation, that a greater degree of satisfaction will be gained by those who have had lower limb operations than is likely to be enjoyed by those who have had upper limb operations. Lengthening of the tendo calcaneus, or arthrodesis of an ankle or of a foot, may enable a previously chair-bound patient to make the simple movements necessary to independent walking, whereas a technically perfect tendon transfer in the hand may fail to provide the intricate and highly coordinated movements required for writing or a pincer grip. Wrist flexion deformity-although it may be accepted in general that surgical treatment of upper limb deformities is less effective in its results, there is one operation in the cerebrally palsied to which this statement does not apply so completely-that is in arthrodesis of the wrist to correct a fixed flexion deformity. Even when there is little hope of increased hand function the operation is justifiable because the improved appearance (Fig. 4) boosts morale. In many cases there is improvement both in function and appearance, and in some this has a reflex influence in fields unrelated to the area of the operation. The elimination of gross athetotic movements after a successful arthrodesis of the wrist will reduce the bombardment of the brain by peripheral stimuli, and correspondingly lessen the need for the initiation of inhibitory efforts; thus greater concentration, with improvement in unrelated spheres such as educational activities, may follow. Functional recovery after operation on the spastic hand of the hemiplegic patient can occur only when there is no asteriognotic or proprioceptive defect. Inability to recognise the shape, size or consistency of an object placed in the affected hand carries a bad functional prognosis and is a contra-indication to surgery, as is the absence of a complete body image. Nevertheless, a better cosmetic appearance is no mean gain. Stretching the severely contracted flexor tendons before operation is advisable by wedged plasters even though a relative lengthening of these tendons is provided at the time of operation by a carpectomy or wedge-shaped resection of the wrist joint. The latter operation favours a THE JOURNAL OF BONE AND JOINT SURGERY

4 SURGICAL TREATMENT OF CEREBRAL PALSY 71 sounder arthrodesis by providing a wider surface of raw bone. In the spastic child correction of the deformity with subsequent immobilisation in plaster is sufficient to ensure union from the cancellous tissue which is packed round the excised wrist and the denuded carpal joints, but in the athetoid it may be necessary to supplement this by means of cortical bone grafts or a metal plate. In most cases immobilisation for several months in a cock-up plaster with the hand in ulnar deviation is required. Even if union fails to occur, and this is unfortunately not uncommon in the athetoid, there is always an improvement in the appearance of the hand. At the time of operation, or subsequently, transfer of the extensor carpi radialis brevis to the extensor pollicis longus may improve the function ofthe thumb, and arthrodesis ofthe carpo-metacarpal and the metacarpo-phalangeal joints of the thumb has, in my experience, been more satisfactory than an Allen strut. Pronation deformity-in the hemiplegic patient the involved or assisting hand functions best in pronation. It seems unnecessary, therefore, to consider surgical correction, especially since the operation is not universally successful. Division or transfer of the pronator radii teres with or without excision of the pronator quadratus has not, in my hands, been a successful operation ; it is claimed that the results of this procedure are enhanced by transfer of the flexor carpi ulnaris to the lower end of the radius, but I have had no experience of this. Painful dystonic shoulder movements-my experience of the Stoeffel type of operation for the upper limb is limited to twelve cases, and does not justify a firm opinion for or against. But the almost complete lack of success in my cases left an unfavourable impression. In contrast, division of the anterior roots of the third cervical to the first thoracic nerve inclusive (Figs. 5 and 6), in two hemiplegic patients who suffered from severe dystonic movements associated with pain, impressed me favourably. The latter operation is destructive in that all movement is abolished and a flail arm results. Despite this, the operation is justifiable on those rare occasions when working efficiency is destroyed and the life of the patient is rendered intolerable by the excessive and uncontrollable movements of the limb. Fortunately, tactile and proprioceptive sensations remain unaffected. FIG. 5 FIG. 6 Case 3-Left spastic hemiplegia with athetosis left arm. Figure 5-Before operation. Figure 6-Twenty years later. After section of the dorsal nerve roots from the third cervical to the first thoracic segments inclusive, the athetosis was completely controlled. Proprioceptive sensation has been retained. Surgical intervention for the correction of deformities of the upper limb was undertaken on only sixty-six occasions in this series of 466 operations. The outcome could be described as successful in only nineteen, or 28 per cent, although an additional sixteen patients claimed to have been helped. There were twenty-seven failures and four patients could not be traced. VOL. 44 B, NO. 1, FEBRUARY 1962 DEFORMITIES OF THE LOWER LIMB Toe deformities-hallux valgus, hallux flexus, and severe claw deformity of the toes can limit the ability of the patient to walk or even to stand for more than a brief period. Although these deformities may occur incidentally in the child with cerebral palsy, they are aggravated by the continuous muscular efforts made to obtain a plantigrade stance and independent balance. Treatment by surgical fusion of the metatarso-phalangeal joint of the great toe and of the interphalangeal joints of the second and third toes, and in the case of the fourth and

5 72 G. A. POLLOCK fifth toes by excision of these joints, will lessen the deformity, relieve pain and improve function. Pes cavus-although pes cavus is probably an incidental finding, it may be aggravated to such an extent by the muscular imbalance of cerebral palsy that surgical correction becomes necessary. Treatment by surgical division of the plantar fascia alone gave a satisfactory result in forty-five of the fifty-three patients subjected to operation. A review of these patients some years later showed a recurrence in eight, and in three of these the recurrent deformity was associated with a medial curvature ofthe calcaneum, as described by Dwyer (1955). Cuneiform osteotomy of the calcaneum from the lateral side corrected the condition. When the deformity is severe and is associated with marked callosity formation a triple arthrodesis is the most satisfactory treatment. Talipes valgus-eversion of the feet, frequently severe, is found in the spastic and in the athetoid patient. It is usually accompanied by tightness of the peroneal and calcaneal tendons with or without mechanical inefficiency or even weakness of the tibialis posterior. The deformity may be increased by the active attempts of the child to obtain a balance by flexing and adducting the hips and knees. Tendon transfer alone is not sufficient to correct this deformity, and it must be combined with some L form of bony stabilisation. Triple arthrodesis, with division of the peroneus longus and brevis and their transfer to the dorsum of the foot or to the navicular bone, will improve the function and appearance of the foot. An attempt has been made in recent years to prevent severe eversion by early operation. When the feet can still be moulded L_ manually into good position a FIG. 7 FIG. 8 talo-calcaneal strut fusion (Grice Case 4. Figure 7-Valgus deformity of feet before operation. 1952) is performed and, at the same Figure 8-Two years after Grice operations. tlme or later, the peroneal tendons are transferred to the dorsum of the foot. The early improvement in appearance and function is encouraging (Figs. 7 and 8). Talipes calcaneus-talipes calcaneus is a feature of the atonic form of cerebral palsy, but it may be found also in the spastic form after over-lengthening of the calcaneal tendon in the surgical correction of talipes equinus. This surgical complication causes a greater degree of disability than the original talipes equinus, functionally as well as from the point of view of corrective surgery. It is predisposed to by strong or spastic dorsiflexors of the ankle. When the deformity is very severe nothing short of a pantarsal arthrodesis-including the ankle, subtalar and midtarsal joints-will provide a stable foot. In two cases in which the deformity was less severe satisfactory correction was obtained by a reversal of the gastrocnemius slide operation used by the author in the treatment of talipes equinus. The gastrocnemius tendon is separated from its attachment to the tendo calcaneus, and the foot is immobilised in extreme plantar flexion to permit reattachment of the gastrocnemius to the tendo calcaneus at a lowei level. Sound union in this new position is ensured by using a strip of gastrocnemius aponeurosis as a living suture or, when it THE JOURNAL OF BONE AND JOINT SURGERY

6 SURGICAL TREATMENT OF CEREBRAL PALSY 73 is present, the plantaris tendon ; in the latter case the distal attachment of the tendon is left undisturbed, the tendon being threaded through the tendo calcaneus and the gastrocnemius fascia and finally sutured to itself at its insertion. After operation the foot is held in plantar flexion by a plaster for at least eight weeks (Figs. 9 and 10). Talipes equinus-talipes equinus is by far the commonest deformity encountered in cerebral palsy. In its mildest form it may be missed in a casual examination which has omitted to include the shoes, but in its fully developed state it presents an inescapable deformity. The increasing tightness of the calcaneal tendon may be due to a defect in the soleus or in the gastrocnemius muscle, or in both. An equinus deformity that can be corrected passively when the knee is flexed but reappears when the knee is extended is due to a tight gastrocnemius, whereas a deformity that remains unaffected by this manoeuvre is due to a tight calcaneal tendon and is predisposed to by weak dorsiflexors of the ankle. When the equinus is of long duration two secondary developments tend to fix the deformity: 1) adaptive contraction of the posterior capsule of the ankle and subtalar joints; and 2) thickening of the part of the FIGS. 9 AND 10 Case 5. Figure 9-Severe calcaneus deformity in atonic form of cerebral palsy. Before operation. Figure 10-After shortening of tendo calcaneus. neck of the talus which, because of the plantar-flexed position of the foot, lies outside the ankle joint mortise. ( onservative treatment-a spastic equinus deformity in children under the age of five will respond to repeated daily stretching with or without night splinting. A more rapid correction is obtained by the application of a plaster which is wedged upwards at the ankle at four-day intervals until the deformity has been over-corrected. Those children, small in number, who prove resistant to this treatment are encouraged to walk in a closed below-knee plaster in which the foot has been dorsiflexed as fully as possible. With each step the calf muscles are stretched and the process can be hastened by further wedging of the foot. Successful results should be obtained in 95 per cent of patients in six to eight weeks. Surgical treatment-this should seldom, if ever, be performed before the child is five years of age and before full conservative measures have had a fair trial. Open lengthening of the tendo calcaneus will always correct a simple talipes equinus deformity. In the spastic patient it is important to lengthen the tendon only sufficiently to permit the foot to be brought up to a right angle. Over-correction beyond this point, especially when the dorsiflexors of the ankle are strong, may cause talipes calcaneus-a worse deformity and one more difficult to correct than the original equinus (Barnett 1952). Subcutaneous lengthening of the calcaneal tendon can give equally good results, but it is less easy to control the degree of lengthening, and the use of excessive force may result in VOL. 44 B, NO. 1, FEBRUARY 1962

7 74 G. A. POLLOCK sudden wide separation of the tendon ends with the development of a calcaneus deformity. It is for these reasons that the method has been condemned (McCarroll and Schwartzmann 1943). If the knee flexion test shows that the equinus deformity is due to a tight gastrocnemius, satisfactory correction is obtained by the gastrocnemius slide operation described by Strayer (1950) and Pollock (1953). This operation is never followed by calcaneus deformity, and the power as well as the shape of the calf is less disturbed. A similar result will follow separation of both heads of the gastrocnemius from the back of the femur (Silfverski#{246}ld 1924, Scaglietti 1955). The muscle division may be combined with resection of part of the nerve supply to each gastrocnemius head; in some cases the posterior capsule of the knee may need to be divided also, and the hamstrings lengthened. The operation is indicated particularly when there is fixed flexion at the knee. equinus In my experience neurectomy has not been successful in the corrective treatment of deformity. Failure to obtain correction of an equinus deformity at the time of lengthening of the tendo calcaneus or gastrocnemius slide indicates the need to divide the posterior thickened FIG. 11 Case 6-Radiographs before and after triple arthrodesis for calcaneo-valgus deformity. capsule of the ankle and subtalar joints. Should this also fail, division ofthe anterior and posterior tibio-fibular ligaments with stripping downwards of the collateral ligaments of the ankle joint to separate the fibula from the tibia is necessary in order to permit the thickened anterior part of the talus to be replaced within the ankle mortise. After the age of twelve a triple arthrodesis of the Lambrinudi type is the most satisfactory treatment for a persistent drop-foot deformity, especially in patients for whom bracing in any shape or form is repugnant. In 128 cases of tendo calcaneus lengthening seventy showed excellent results. Ten of twelve patients with short spastic gastrocnemii were treated successfully by the gastrocnemius slide operation. Failures may be attributed to three main causes: 1) inadequate, excessive or premature lengthening; 2) lengthening the tendo calcaneus when the fault lay in the gastrocnemius alone; 3) failure to maintain the correction obtained at operation by the prolonged use of braces or splints and physiotherapeutic care. Inadequate care after operation is the commonest cause of failuie and, therefore, of recurrence of the deformity. A predisposition towards such a state is present when the dorsiflexors of the ankle are weak or the calf muscles are in spasm (Green and McDermott 1942, Phelps 1957). To this, a third factor, the disproportion in the rate of growth of bone and soft tissue, may be added, a finding reported by Sharrard in poliomyelitis (1959). For these reasons prolonged and adequate post-operative physiotherapy and the use of calipers until growth ceases are evident necessities. Attention to these factors in recent years has increased the number of successes from lengthening of the tendo calcaneus. Triple arthrodesis of the foot-lateral instability of the foot, talipes-equino-varus, calcaneovalgus (Fig. 11), or severe eversion deformities delay and may even prevent the acquisition of a good standing balance. Manipulation, fixation in plaster, and the prolonged use of below-knee calipers will help many of the less severely affected children to stand and walk, THE JOURNAL OF BONE AND JOINT SURGERY

8 SURGICAL TREATMENT OF CEREBRAL PALSY 75 but when the deformity is severe, only surgical correction, as perfected by Ryerson, Dunn, Hoke or Lambrinudi, will give a satisfactory aesthetic and functional result. Flexion deformity at the knee-when flexion deformity at the knee is fully developed it may be impossible to state which factor was primary and which secondary in its causation. Barnett (1952) pointed out that straightening of the knees when the patient is placed supine in bed suggests that the flexion at the knee is secondary to a contracture at the hip. Whether knee flexion develops as an adaptation to an equinus deformity from a tight calcaneal tendon or as a sequel to a flexion contracture at the hip or is due to an initial spasm with contracture of the hamstring muscles themselves, initiated or perpetuated by a weak quadriceps, is of academic interest. The important point is to ensure that all the factors should be recognised and removed, whereupon a successful outcome to treatment is assured. In the milder forms of flexion of the hip or knee conservative measures of correction, by wedged plaster (McCarroll and Schwartzmann 1943), by Dame Agnes Hunt plasters, or by the Schwartz frame, may succeed if followed by adequate physiotherapy and caliper stretching. In the severer forms surgical intervention is required : 1) to divide, lengthen or transfer the hamstring tendons ; 2) to detach the origin or insertion of the gastrocnemius ; 3) to advance FIG. 12 F:G. 13 Case 7. Figure 12-Spastic tetraplegia, before operation. Figure 13- Seven and a half years after hamsti ing transfer. the patellar insertion ; or 4) to perform a posterior capsulotomy. Of these various procedures hamstring transfer, described by Eggers (1950, 1952) has given the most successful results (Figs. 12 and 13). Division of the patellar retinacula with transfer of all three hamstrings, as advised by Eggers originally, is not now performed. The late development of genu recurvatum in some patients caused us to modify the Eggers technique. One hamstring, either the semitendinosus or the semimembranosus-whichever is the least contracted-is now left, or perhaps lengthened by Z -plasty. Conservation of one hamstring tendon has lessened the tendency to genu recurvatum and has preserved some active flexion against gravity. It is not necessary to drill the femur to attach the tendons to the bone: suture of the divided tendon to VOL. 44 B, NO. 1, FEBRUARY 1962

9 76 G. A. POLLOCK the fibrous tissue underlying the gastrocnemius origin, or in the case of the medial hamstring to the adductor insertion, is sufficient and technically simpler. Of nineteen patients (thirty-six transfers) followed up for five years, four patients (eight operations), all mentally retarded and without an independent standing balance, and one patient also blind, can now walk with straight legs using a trolley. Seven patients (fourteen operations) who could not walk before operation now do so independently or with a little support. One patient died two months after operation from a convulsive seizure, and two operations were initially unsuccessful in consequence of a fracture of the lower end of the femur; both may yet gain independence after further surgical treatment. The remaining five patients are steadily increasing their range ofactivity, although a supporting arm or Bon-A-Ped is still necessary. The most dramatic results will be obtained when an independent standing and walking balance is present already, and when there has been no previous lengthening of the tendo calcaneus. Treatment for a tight calcaneal tendon should be postponed until after the hamstring tendons have been successfully transferred, when it will be found that many, which were previously considered in need of surgical lengthening, have been stretched adequately during the period of plaster immobilisation after the tendon transfer. It is desirable to correct a severe hip flexion deformity before the hamstring transfer either by conservative or surgical measures. A high-riding patella, a long patellar tendon, and a weak quadriceps muscle-a frequent accompaniment of long-standing flexion deformity at the knee-although improved considerably by the Eggers operation, may require advancement of the patellar insertion (Chandler 1933) before the knee can be extended. In two cases in which excision ofthe patella with reefing of its capsule and adjacent quadriceps tendon was performed the extension lag at the knee was corrected. Severe flexion deformity persisting at the knee or at the hip aftet division of the soft tissue will respond to an osteotomy of the femur (Thibodeau, Wagner and Carr 1939). A frequent criticism of the hamstring lengthening operation is that the patient has an unstable balance afterwards. This may be true in some, but the improvement in appearance and in gait afforded by walking with a straight knee, often unbraced, gives a greater boost to morale than is provided by any other known form of treatment. DEFORMITIES AT THE HIP Four types ofdeformity at the hip are common in patients with cerebral palsy : 1) adduction; 2) flexion ; 3) medial rotation ; and 4) subluxation and dislocation. Adduction deformity at the hip is the commonest disability and as a deformity due to cerebral palsy is second only to talipes equinus in frequency. It is due mainly to overaction of strong or spastic adductor muscles in the presence of weak abductors, particularly the gluteus medius. Whether thete is true weakness of the abductors orjust a functional inefficiency the result is the same : the child gains a standing balance only by bringing his knees together. Eventually the less severely handicapped patient will walk independently with his lower limbs medially rotated and flexed at the hip and knees, and in a rather stamping equinus fashion ; but the severely affected child can be mobile only when supported from in front by a stick or article of furniture firmly grasped, and his gait is of the scissors type with everted and laterally rotated feet. In many cases the adduction eventually leads to subluxation of the hip. Treatment-Adductor tenotomy is the simplest and quickest method of correcting the deformity and the attendant scissors gait. The operation should, however, be preceded by a muscle test, because division of the adductor muscles when the abductors are powerless may render a previously mobile patient bedridden, until the adductors have again contracted. An extensive adductor tenotomy. especially if it has been accompanied or preceded by a complete abdominal THE JOURNAL OF BONE AND JOINT SURGERY

10 SURGICAL TREATMENT OF CEREBRAL PALSY 77 obturator neurectomy, may have even more serious consequences in that the patient may never walk again independently. If any doubt exists, the adductor muscles should be put out of action temporarily by the injection of a local anaesthetic. This simple test is a valuable pre-operative safeguard which should never be omitted. At operation only the adductor longus, adductor brevis and gracilis muscles are divided, with or without removal of one inch ofthe anterior branch ofthe obturator nerve. Ifthe deformity is severe. crushing ofthe posterior division of the obturator nerve (Barnett 1952) may permit full correction at the time. In the ensuing months, before the posterior branch has regenerated, the weak abductors may be developed by physiotherapy, to provide an adequate opposition to the reduced adduction pull. Ifan adductor tenotomy is contra-indicated for one reason oi another, and simple tlaction on an abduction frame is ineffective, a femoral osteotomy is a valuable alternative. Results-Adductor tenotomy was performed forty times with an immediate successful outcome in most patients, but when a review was undertaken some years later a recurrence of the FIGS. 14 AND 15 Case 8. Figure 14-Adductor paralysis, before operation. Figure 15-One year after complete hamstring transfer (author s method). deformity was found to have taken place in twenty-one cases. In some, imbalance between the recovering adductors and abductors was the cause of the failure; in others an overenthusiastic division of muscle may have contributed to the poor results, but the major cause lay in inadequate splinting and physiotherapy after operation. Abdominal obturator neurectomy was done fourteen times; the antero-medial twothirds of the nerve was removed over a distance of one inch and in two cases the whole nerve was divided. Four years later only three patients were considered to be satisfactory. A combination of neurectomy and myotomy is more satisfactory. Similar results have been reported by Thibodeau et al. (1939), Chandler (1939) and McCarroll and Schwartzmann (1943). The two patients subjected to combined abdominal obturator neurectomy and extensive adductor tenotomy were unable to adduct the thighs, which lay in full abduction, lateral rotation and flexion (Figs. 14 and 15). Complete transposition of the hamstring muscles in VOL. 44 B, NO. 1, FEBRUARY 1962

11 78 G. A. POLLOCK Case 9. Figure 16-Subluxation of the hip. Figure 17-After derotation and varus osteotomy. Case 10. Figure 18-Subluxation of the left hip. Figure 19-After Lorenz operation. THE JOURNAL OF BONE AND JOINT SURGERY

12 SURGICAL TREATMENT OF CEREBRAL PALSY 79 two stages corrected the deformity (Pollock 1957). The tendons of insertion were transplanted to the lower end of the femur at the first operation, and two months later the origins of the muscles were transferred to the pubic rami. Now, almost two years later, both patients can walk between parallel bars or with a Bon-A-Ped walker, and the power with which adduction was performed was estimated at 3, compared with a normal 5 (Medical Research Council grading). Flexion deformity-flexion at the hip may be due to strong or spastic hip flexor muscles inadequately counterbalanced by the hip extensors, or it may develop as part of the knee/hip flexion with equinus deformity. When the deformity is well established it is difficult to decide which is the primary and which the secondary factor. FIG. 20 FIG. 21 Case 11. Figure 20-Spastic tetraplegia with bilateral hip dislocation. Patient bedridden. Figure 21-Two years after closed reduction of the left hip and arthrodesis of the right hip; and triple arthrodesis of left foot. Patient walking independently with Bon-A-Ped walker. Treatment-The less severe degrees of flexion deformity can be corrected or improved by simple traction on a Jones s abduction frame or by the Agnes Hunt method. When conservative measures fail an extensive muscle slide operation such as that advised by Campbell (1939) or Soutter (1949) is necessary. The tensor fasciae latae, the sartorius and both heads of the rectus femoris muscles are freed. The capsule of the hip is opened and the ilio-femoral ligament divided. In a few it may be necessary to divide the psoas tendon also. Shortening of the femoral vessels and nerves may determine the final degree of correction, as in flexion deformity at the knee. When this is found to be the limiting factor, shortening ofthe femur by osteotomy may be justified, the divided ends being re-united by a plate. Medial rotation-medial rotation deformity is the result of the bad sitting attitude instinctively adopted by the child in his endeavour to gain an independent sitting balance. The thighs are flexed, medially rotated and abducted, and the knees are flexed to a right angle. This attitude provides a wide sitting base for a child with an otherwise inadequate balance. Treatment-Treatment by division of the ilio-femoral ligament allows the leg to roll outwards and so corrects the deformity when soft tissues alone are affected. When the deformity is of long duration, with bone changes, only a derotation osteotomy of the upper end of the femur will correct it. VOL. 44 B, NO. 1, FEBRUARY 1962

13 80 G. A. POLLOCK Dislocation and subluxation-in a recent review of 104 cases of cerebral palsy, Lamb (1959) found radiological evidence of dislocation (unilateral or bilateral) in sixty-three ; in only one was there a true congenital dislocation. Pollock and Sharrard (1958) suggested that the true incidence of dislocation of the hip in cerebral palsy is in the neighbourhood of 5 per cent. Severe adductor spasm is the main factor in producing the dislocation, but a valgus neck which is anteverted is a contributory factor. Flexion spasm or the flexion with adduction which accompanies a marked asymmetrical tonic neck reflex may exert a precipitating effect. Treatment-Treatment by wide abduction of the legs with or without adductor tenotomy may be sufficient to correct the deformity. Others again require major surgical measures such as varus osteotomy to correct the valgus deformity of the femoral neck, the fragments being secured in position by a nail-plate (Figs. 16 and 17). This operation alone, or supplemented by a derotation osteotomy, was performed on eight occasions, with success in six. The two failures could have been avoided had internal fixation been performed. Lorenz osteotomies (Figs. 18 and 19) in two cases and Schanz osteotomies in three were followed by success in four and improvement in one. Arthrodesis by the method of Brittain or by intra-articular fusion, alone or combined with derotation, was successfully performed in six cases (Figs. 20 and 21) and unsuccessfully in one. Leg lengthening-occasional growth defect in hemiplegia may be difficult to explain in simple terms oftrophic disturbance, impaired muscle pull or diminished blood supply. Leg lengthening was satisfactorily accomplished in three children. In another six the unaffected side was shortened after growth had ceased. Epiphysial stapling at the knee is a less accurate alternative. SUMMARY AND CONCLUSIONS 1. Thirteen years of experience in charge of treatment in a Residential School for Cerebral Palsy, and a review of 466 operations performed on children handicapped by this condition, form the basis for this attempt to frame the indications and contra-indications for operation. 2. A briefdescription is given ofthe more commonly performed operations, with an indication of the results that are likely to be obtained. 3. Orthopaedic surgery has a worth-while contribution to make in the treatment of cerebral palsy. When the cases are selected with care, when the appropriate orthopaedic measures are skilfully performed and when the patients are adequately supervised afterwards, the benefits of surgery are greater than those provided by any other treatment, and they are achieved more quickly. 4. The desire to improve and the inner urge of the patient to succeed may be the most important single factor in his rehabilitation. REFERENCES BAKER, L. D. (1956): A Rational Approach to the Surgical Needs of the Cerebral Palsy Patient. Journal of Bone and Joint Surgery, 38-A, 313. BARNETT, H. E. (1952): Orthopedic Surgery in Cerebral Palsy. Journal of the American Medical Association, 150, 1,396. CAMPBELL, W. C. (1939): Operative Orthopedics, pp St Louis: The C. V. Mosby Company. CHANDLER, F. A. (1933): Re-establishment of Normal Leverage of the Patella in Knee Flexion Deformity in Spastic Paralysis. Surgery, Gynecology and Obstetrics, 57, 523. DWYER, F. C. (1955): A New Approach to the Treatment of Pes Cavus. Soci#{233}t#{233} Internationale de Chirurgie Orthop#{233}dique et de Traumatologie. Sixi#{232}me Congr#{232}s International de Chirurgie orthop#{233}dique Berne, 30 ao#{252}t-3septembre Proc#{232}s-verbaux, etc., p Bruxelles: Imprimerie Lielens. EGGERS, G. W. N. (1950): Surgical Division of the Patellar Retinacula to Improve Extension of the Knee Joint in Cerebral Spastic Paralysis. Journal of Bone and Joint Surgery, 32-A, 80. EGGERS, G. W. N. (1952): Transplantation of Hamstring Tendons to Femoral Condyles in Order to Improve Hip Extension and to Decrease Knee Flexion in Cerebral Spastic Paralysis. Journal of Bone and Joint Surgery, 34-A, 827. THE JOURNAL OF BONE AND JOINT SURGERY

14 SURGICAL TREATMENT OF CEREBRAL PALSY 81 GREEN, W. T., and MCDERMOTF, L. J. (1942): Operative Treatment of Cerebral Palsy of Spastic Type. Journal of the American Medical Association, 118, 434. GRICE, D. S. (1952): An Extra-Articular Arthrodesis of the Subastragalar Joint for Correction of Paralytic Flat Feet in Children. Journal ofbone and Joint Surgery, 34-A, 927. L,i.iB, D. W. (1959): Hip Deformities in Cerebral Palsy. Paper read at combined C.M.A./B.M.A. Meeting in Edinburgh, July LITFLE, W. J. (1862): On the Influence of Abnormal Parturition, Difficult Labour, Premature Birth, and Asphyxia Neonatorum, on the Mental and Physical Condition of the Child, Especially in Relation to Deformities. Transactions of the Obstetrical Society oflondon, 3, 293. MCCARROLL, H. R., and SCHWARTZMANN, J. R. (1943): Spastic Paralysis and Allied Disorders. Journal of Bone andjoint Surgery, 25, 745. O CoNNoR, N., and CLARIDGE, G. S. (1955) : The Effect of Goal-setting and Encouragement on the Performance of Imbecile Men. Quarterly Journal ofexperimental Psychology, 7, 37. O CONNOR, N., and TIZARD, J. (1954): A Survey of Patients in Twelve Mental Deficiency Institutions. British Medical Journal, i, 16. PHELPS, W. M. (1957): Long-term Results of Orthopaedic Surgery in Cerebral Palsy. Journal of Bone and Joint Surgery, 39-A, 53. POLLCCK, G. A. (1953): Lengthening of the Gastrocnemius Tendon in Cases of Spastic Equinus Deformity. Journcl cf Bone andjoint Surgery, 35-B, 148. POLLOCK, G. A. (1958): Treatment of Adductor Paralysis by Hamstring Transposition. Journal of Bone and Joint Surgery, 40-B, 534. POLLOCK, G. A., and SHARRARD, W. J. W. (1958): In Recent Advances in Cerebral Palsi. Edited by R. S. Illingworth. Chapter 14, pp London: J. & A. Churchill Ltd. SCAGLIETTI, 0. (1955): Le detachment des muscles gastrocn#{233}miens dans le traitement sanglant du pied #{233}quin spastique. Soci#{233}t#{233} Internationale de Chirurgie Orthop#{233}dique et de Traumatologie. Sixi#{232}meCongr#{233}s International de Chirurgie orthop#{233}dique Berne 30 ao#{252}t-3septembre Proc#{232}s-verbaux, etc., p Bruxelles : Imprimerie Lielens. SHARRARD, W. J. W. (1959): Congenital Paralytic Dislocation of the Hip in Children with Myelo-meningocele. Journal of Bone and Joint Surgery, 41-B, 622. SILFVERSK1OLD, N. (1924): Reduction of the Uncrossed Two-joints Muscles of the Leg to One-joint Muscles in Spastic Conditions. Acta Chfrurgica Scandinavica, 56, 315. SOUTFER, R. (1949): Quoted in Campbell s Operative Orthopedics. Edited by J. S. Speed and H. Smith. Second edition, vol. 2, p. 1,042. London: Henry Kimpton. STRAYER, L. M. (1950): Recession of the Gastrocnemius. An Operation to Relieve Spastic Contracture of the Calf Muscles. Journal of Bone and Joint Surgery, 32-A, 671. THIBODEAU, A. A., WAGNER, L. C., and CARR, F. J., Jun. (1939): The Evaluation of Surgical Procedures on Bones, Muscles and Peripheral Nerves in Spastic Paralysis. American Journal of Surgery, 43, 822. VOL. 44 B, NO. 1, FEBRUARY 1962

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