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

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