Lower Extremity Orthopedic Surgery in Cerebral Palsy. Hank Chambers, MD Rady Children s Hospital - San Diego

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1 Lower Extremity Orthopedic Surgery in Cerebral Palsy Hank Chambers, MD Rady Children s Hospital - San Diego

2 Indications Fixed contracture Joint dislocations Shoe wear problems Pain Perineal hygiene problems

3 What can Orthopedic Surgery Offer? Lengthen tendons Transfer tendons Relocate joints Rotate bones Fuse joints

4 Principles of Orthopedic Surgery in Cerebral Palsy Single event, multilevel surgery Delay surgery as long as possible (> 6 years) Use spasticity management as adjunct to surgery

5 The Diving Syndrome

6 Timing of Surgery Boyd, Graham et al Eur J Neur 6(supp 4), 1999

7 Soft tissue contractures Bony abnormalities Morphology Rotation

8 Spine Problems Scoliosis Spondylolisthesis

9 Hip Adduction Deformity Open vs percutaneous lengthening of adductors? Obturator neurectomy Canale and Beaty Operative Pediatric Orthopedics 1991

10 Adductor Lengthening Obturator Neurectomy Canale and Beaty Operative Pediatric Orthopedics

11 Hip Flexion Deformity Usually caused by contracture of the iliopsoas muscle Sartorius, rectus femoris and tensor fascia femoris muscle can also contribute

12 Treatment of Hip Flexion Contractures Canale and Beaty Operative Pediatric Orthopedics 1991

13 Psoas lengthening at the Pelvic Brim

14 Hip Subluxation & Dislocation Acetabular Dysplasia Hip Subluxation

15 Hip Subluxation & Dislocation Indications for Treatment: Hip subluxation in any condition Pain Loss of sitting ability

16 Proximal Femoral Varus Derotational Osteotomies Indications for surgery: d valgus d femoral anteversion

17 Acetabular Dysplasia Usually posterior dysplasia Anterior Posterior Mid-superior

18 Treatment of Acetabular Dysplasia Periacetabular Osteotomy, Open Reduction and VDRO

19 San Diego Approach to Hip Dislocation

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22 Salvage Procedure for Hip Dysplasia Interposition arthroplasty

23 Problems at the Knee Crouch gait Jump gait Stiff knee gait Recurvatum gait

24 Crouch Gait Increased hip flexion Increased knee flexion Increased ankle dorsiflexion (calcaneous) Usually iatrogenic

25 Patella Alta

26 Jump Gait In di or hemiplegia Increased hip flexion Increased knee flexion Increased ankle plantar flexion

27 Hamstring Lengthening

28 Stiff Knee Gait Manifest by swing phase knee stiffness Leads to problems of foot clearance Compensatory mechanisms include Hip Circumduction External Rotation Contralateral vaulting

29 Rectus Femoris Transfer

30 Recurvatum Gait Usually iatrogenic Difficult to treat surgically Often need long leg braces (KAFO with the ankle in dorsiflexion)

31 KNEE PROBLEMS IN ADULTS WITH CEREBRAL PALSY Patellofemoral arthritis Patellar malalignment syndrome Meniscal tear Cruciate ligament tears

32 Rotational Abnormalities Lever Arm Syndrome Increased Femoral Anteversion Increased internal or external tibial torsion malignant malalignment syndrome Patellar subluxation/dislocation Foot valgus

33 Treatment Femoral osteotomies Proximal Distal? Gluteus medius transfer Tibial derotational osteotomies Correction of valgus in foot

34 Problems at the Foot & Ankle Equinus Calcaneous Varus Valgus Bunion

35 Treatment Options for Equinus Lengthening of the fascia (recession) Strayer Baker Vulpius Baumann Lengthening of the Tendoachilles

36 Equinus Open Tendoachilles Lengthening Gastrocnemius Recession Strayer or Vulpius

37 Calcaneous Usually iatrogenic

38 Treatment Options for Calcaneous Surgical: Muscle transfer to heel TA, TP, PL, PB, FDL, FHL Heel cord tenodesis Osteotomy of calcaneus (can combine with muscle transfer) Oblique Crescentic

39 The Varus Foot

40 Varus Foot Deformity Usually in hemiplegia Surgical Options include Frost Lengthening of the Posterior Tibialis Muscle Split Posterior Tibialis Tendon Transfer (SPOTT) Split Anterior Tibialis Tendon Transfer (SPLATT)

41 Frost Tibialis Posterior Tendon Lengthening Tibialis Posterior

42 Split Posterior Tibialis Tendon Transfer (SPOTT)

43 Split Anterior Tibialis Tendon Transfer (SPLATT)

44 Valgus Foot Common in diplegia & quadriplegia

45 Treatment Options for the Valgus Foot Peroneus Brevis Tendon Lengthening Calcaneal Lengthening Calcaneal Sliding Osteotomy Subtalar Arthrodesis Triple Arthrodesis

46 Peroneus Brevis Lengthening

47 Subtalar Arthrodesis

48 Subtalar Stapling

49 Evan s Calcaneal Lengthening

50 Sliding Calcaneal Osteotomy

51 Triple Arthrodesis

52 Look for Ankle Valgus

53 Bunion Deformities Dorsal bunion Hallux valgus

54 Treatment Standard bunion procedure Arthrodesis

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