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  1. 1. Orthopaedic Update in Cerebral Palsy:Common Surgical Procedures and Postoperative Rehabilitation Lael Luedtke, MD Sue Murr, PT Gillette Children’s Specialty Healthcare
  2. 2. Cerebral Palsy <ul><li>Static Encephalopathy </li></ul><ul><li>Imposed on developing neurologic system and skeleton </li></ul><ul><li>… results in… </li></ul><ul><li>impairment of control of movement and posture </li></ul>
  3. 3. Types of Cerebral Palsy <ul><li>CP classified by: </li></ul><ul><ul><li>Tone type </li></ul></ul><ul><ul><li>Distribution of affected areas (extremities, trunk, head) </li></ul></ul>
  4. 4. Tone Types and Movement Disorders <ul><li>Spasticity </li></ul><ul><li>Athetosis </li></ul><ul><li>Rigidity </li></ul><ul><li>Ataxia </li></ul><ul><li>Hypotonia </li></ul><ul><li>Mixed </li></ul>
  5. 5. Distribution <ul><li>Hemiplegia </li></ul><ul><li>Monoplegia </li></ul><ul><li>Diplegia </li></ul><ul><li>Quadriplegia </li></ul><ul><li>Triplegia </li></ul><ul><li>Double Hemiplegia </li></ul>
  6. 6. Cerebral Palsy Spastic Quadriplegia
  7. 7. Spastic Quadriplegia <ul><li>Preoperative Evaluation: </li></ul><ul><li>Examination Based </li></ul><ul><li>Issues: </li></ul><ul><ul><li>Hygiene </li></ul></ul><ul><ul><li>Seating </li></ul></ul><ul><ul><li>Standing </li></ul></ul><ul><ul><li>Shoe Wear </li></ul></ul>
  8. 8. Spastic Quadriplegia <ul><li>Areas of Orthopaedic Concern: </li></ul><ul><li>Spine </li></ul><ul><li>Hips </li></ul><ul><li>Knees </li></ul><ul><li>Feet/Legs </li></ul><ul><li>Upper Extremity Caveat </li></ul>
  9. 9. Spastic Quadriplegia - Spine <ul><li>Neuromuscular Scoliosis: </li></ul><ul><li>Not generally responsive to bracing </li></ul><ul><li>Relentlessly progressive </li></ul><ul><li>Deformity in both sagittal and coronal planes </li></ul><ul><li>Surgical intervention indicated when curve approaches 45º </li></ul>
  10. 10. Spastic Quadriplegia - Spine <ul><li>Surgical treatment is usually fusion (arthrodesis) of high thoracic spine to sacrum </li></ul><ul><li>Surgical Options: </li></ul><ul><li>Posterior Approach Only </li></ul><ul><li>Anterior plus Posterior Approaches </li></ul>
  11. 11. Spastic Quadriplegia - Hip <ul><li>Subluxation: </li></ul><ul><li>Femoral head partially losing contact with acetabulum </li></ul><ul><li>Dislocation: </li></ul><ul><li>Femoral head completely disengaged from acetabulum </li></ul>
  12. 12. Spastic Quadriplegia - Hip <ul><li>Subluxation: </li></ul><ul><li>Usually progresses to dislocation </li></ul><ul><li>Evident at about 5 years of age </li></ul><ul><li>Combination of femoral neck valgus and persistent anteversion PLUS soft tissue contractures PLUS deformity of acetabulum </li></ul>
  13. 13. Spastic Quadriplegia - Hip <ul><li>Subluxation Treatment: </li></ul><ul><li>Must treat everything contributing to deformity… </li></ul><ul><li>otherwise, like Arnold… </li></ul><ul><li>you will be back. </li></ul>
  14. 14. Spastic Quadriplegia - Hip <ul><li>Dislocation: </li></ul><ul><li>Usually not painful initially, but will become so </li></ul><ul><li>Usually try to reduce but if very stiff and chronic, cannot be done </li></ul><ul><li>Significant pelvic obliquity </li></ul>
  15. 15. Spastic Quadriplegia - Hip <ul><li>Dislocation Procedures </li></ul><ul><li>Reduction: usually requires same procedures as for subluxation </li></ul><ul><li>Proximal Femoral Resection: aka “Girdlestone;” no guarantee of pain relief </li></ul>
  16. 16. Spastic Quadriplegia - Hip <ul><li>Soft Tissue Contractures </li></ul><ul><li>ADDUCTION & FLEXION </li></ul>
  17. 17. Spastic Quadriplegia - Knee <ul><li>Flexion Contractures: difficulties with hygiene, seating, sleeping </li></ul><ul><li>Treatment: soft tissue releases; followed by splinting at night </li></ul>
  18. 18. Spastic Quadriplegia - Feet <ul><li>Variety of Positions: combinations of varus, valgus, equinus and calcaneus; usually RIGID </li></ul><ul><li>Soft tissue procedures plus bony fusions to keep plantigrade for shoe wear and transfers/standing </li></ul>
  19. 19. Spastic Quadriplegia Postoperative Rehabilitation
  20. 20. Goals of postoperative rehabilitation <ul><li>Improved seating and positioning </li></ul><ul><ul><li>Improve comfort </li></ul></ul><ul><ul><li>Maximize use of upper extremities for function </li></ul></ul>
  21. 21. Goals of postoperative rehabilitation, continued <ul><li>Maintain standing as long as possible for bone integrity </li></ul><ul><li>Improve or maintain respiratory function </li></ul>
  22. 22. Immediate Postoperative Care <ul><li>Hip spica casts: generally used when a pelvic osteotomy has been performed </li></ul><ul><li>Transfers are performed by one or two person lifts with or without a sliding board. </li></ul><ul><li>Positioning in bed and reclining wheelchair for comfort and function </li></ul>
  23. 23. Physical therapy after cast removal <ul><li>Passive mobilization with whirlpool and range of motion exercises </li></ul><ul><li>Gradual resumption of developmental activities </li></ul><ul><li>Resume sitting in own wheelchair with necessary modifications, especially when leg length discrepancy is present </li></ul><ul><li>Resume use of stander </li></ul>
  24. 24. Spastic Diplegia/Hemiplegia
  25. 25. Spastic Diplegia/Hemiplegia <ul><li>Evaluation is often based on Gait Lab Analysis </li></ul><ul><li>Important that any spasticity modifying procedures or drugs be instituted BEFORE gait lab </li></ul>
  26. 26. Spastic Diplegia/Hemiplegia <ul><li>Gait Lab Components: </li></ul><ul><li>ROM, Strength and Rotation Assessment </li></ul><ul><li>Motion Sensors (Kinetics and Kinematics) </li></ul><ul><li>EMG </li></ul><ul><li>Oxygen Consumption </li></ul>
  27. 27. Spastic Diplegia/Hemiplegia <ul><li>Procedures performed: </li></ul><ul><li>Osteotomies </li></ul><ul><li>Soft Tissue Modifications </li></ul><ul><li>Muscle Transfers/Lengthenings </li></ul>
  28. 28. Spastic Diplegia/Hemiplegia <ul><li>Osteotomies </li></ul><ul><li>Rotational: </li></ul><ul><ul><li>Femoral </li></ul></ul><ul><ul><ul><li>Proximal - Varus +/- Derotation </li></ul></ul></ul><ul><ul><ul><li>Distal - Extension </li></ul></ul></ul><ul><ul><li>Tibial Derotation </li></ul></ul><ul><ul><li>Os Calcis Lengthening </li></ul></ul>
  29. 29. Spastic Diplegia/Hemiplegia <ul><li>Soft Tissue Modifications: </li></ul><ul><li>Contractures: about hip, knee, ankle joints </li></ul><ul><li>Laxity: patellar tendon advancement </li></ul>
  30. 30. Spastic Diplegia/Hemiplegia <ul><li>Muscle Transfers/Lengthenings: </li></ul><ul><li>Rectus Femoris Transfer </li></ul><ul><li>Gastrocnemius Lengthening </li></ul><ul><li>Anterior/Posterior Tibialis Split Transfers </li></ul>
  31. 31. Spastic Diplegia/Hemiplegia Postoperative Rehabilitation
  32. 32. Spastic Diplegia/Hemiplegia <ul><li>Stages of Recovery after surgery </li></ul><ul><ul><li>Healing of bone and soft tissues: approximately six weeks </li></ul></ul><ul><ul><li>Strengthening of muscles: approximately twelve weeks </li></ul></ul><ul><ul><li>Retraining of gait: up to twelve months </li></ul></ul>
  33. 33. Physical Therapy Goals and Procedures: Initial Three Weeks <ul><li>Prevent stiffness during the period of immobilization </li></ul><ul><ul><li>Positioning - supine without pillows, prone </li></ul></ul><ul><ul><li>Passive range of motion - performed by caregiver or CPM </li></ul></ul>
  34. 34. Physical Therapy Goals and Procedures: Initial Three Weeks <ul><li>Transfers </li></ul><ul><ul><li>Generally dependent lift or with patient assisting with upper extremities </li></ul></ul>
  35. 35. Physical Therapy Goals and Procedures: Three to Six Weeks <ul><li>Range of Motion </li></ul><ul><ul><li>Passive and active assisted with no limitations </li></ul></ul><ul><li>Strengthening </li></ul><ul><ul><li>Isolated exercise and transitional activities based upon selective motor control </li></ul></ul><ul><li>Ambulation </li></ul><ul><ul><li>With appropriate assistive device </li></ul></ul>
  36. 36. Physical Therapy Goals and Procedures: Six to Twelve Weeks <ul><li>Range of Motion </li></ul><ul><ul><li>Routine stretching program resumed </li></ul></ul><ul><ul><li>May continue with use of knee immobilizers at night </li></ul></ul>
  37. 37. Physical Therapy Goals and Procedures: Six to Twelve Weeks <ul><li>Strengthening </li></ul><ul><ul><li>Two to three times per week </li></ul></ul><ul><ul><li>Resistance training, swimming, biking, horseback riding </li></ul></ul>
  38. 38. Physical Therapy Goals and Procedures: Six to Twelve Weeks <ul><li>Ambulation </li></ul><ul><ul><li>Progresses by increasing distance and speed </li></ul></ul><ul><ul><li>Wean from assistive device, may transition to Lofstrand crutches or resume independent ambulation </li></ul></ul>
  39. 39. Physical Therapy Goals and Procedures: Six to Twelve Weeks <ul><li>Orthoses </li></ul><ul><ul><li>AFO style: PLS (posterior leaf spring), solid ankle or dynamic AFO, or FRO (floor reaction AFO) </li></ul></ul>
  40. 40. Discharge from/reduction in Physical Therapy <ul><li>Patient has achieved or exceeded pre-operative functional status </li></ul><ul><li>Therapy may continue at the same frequency as before surgery, or discontinued </li></ul><ul><li>Periodic strengthening, ongoing stretching programs and aerobic exercise is beneficial </li></ul>