Transcript Cerebral Palsy

Cerebral palsy
and its sequelae..
(consequences)
Cerebral Palsy
Was first described by William Little in 1862.
Then it was known as Little disease.
The term Cerebral palsy originated with Freud.
Definition
In all cases the following must be true…
Cerebral palsy is the result of a brain lesion. Therefore, the spinal cord
and muscles are structurally and biochemically normal.
The brain lesion must be fixed and non progressive. Thus, all of the
progressive neuro degenerative disorders are excluded from the
definition.
The abnormality of the brain result in motor impairment.
Epidemiology



The Incidence is between 2.4-2.7 per 1000
live births.
The risk of cerebral palsy in a child born full
term is app.1 in 2000.
The incidence has been correlated with
gestational age and birth weight.
Etiology
Divided into 3 time periods…
Prenatal

Maternal infection and toxins (TORCHES).

Fetal exposure to drugs and alcohol through maternal .(cocaine, heroin
,marijuana)

Congenital malformations of the brain that occur during early pregnancy.

Rhesus blood group incompatibility resulting in kernicterus.

Maternal health problems. ex: RF-Infections.

Prenatal chorioamnionitis and maternal infections and placental abnormalities.
Perinatal

Anoxia as a result of perinatal complications.

Fetal distress.

Premature delivery.

Sepsis in neonatal period.

Bronchopulmonary dysplasia and prolonged ventilation in preterm infants.

Heart surgery before the age of 1mnth.
Postnatal

Infections in early childhood (meningitis).

Any episode of hypoxia.

Trauma and head injuries.
Classification
Physiologic classification
Describes the type of movement disorder present…
 Spasticity: the most common. Increased tone in the extremities.. (the
Clasped knife model)
 Hypotonia: usually a phase, leading most frequently to spasticity.
 Dystonia: lead pipe model.
 Athetosis: abnormal writing movements, patient cannot control.
 Ataxic: in cerebellar lesions.
Patients frequently have a mixed form of movement disorders.
Geographic classification
Describes what part of body is affected..
 Hemiplegia: one side, upper usually more involved.
 Diplegia: both sides, with both lower extremities and lesser involvement
of upper extremities.
 Triplegia: both lower and one upper extremity.
 Quadriplegia: Total body involvement.
Spastic Diplegia
Spastic quadriplegia
Evaluation
Diagnosing..
 Obtaining a complete
history (birth history, birth
weight, complications
following birth..)
 Asking about the child’s
preferential use of one hand
or leg.
 Related medical conditions
(seizures, speech
disorders)
Physical examination..
 Increased muscle tone.
 Deep tendon reflexes are
increased.
 Fine motor activities testing.
 Retained infantile reflexes.
 Balance, sitting and gait of
child.
Treatment
Treatment, Surgical or nonsurgical, must be goal
oriented..
The goals of treatment that have linked to productive
lives as adults are: Communication, education,
mobility and ambulation.
Treatment ranges from observation, physical therapy,
medications.. to surgery.
Treatment..
Physical therapy..
Often the first rendered to the child with cerebral palsy.
No controlled studies have confirmed that regular
physical therapy improves the out come of the child
with cerebral palsy.
The approach to physical therapy is to establish a
therapy to monitor the developmental milestones of
the very young child around the age 2-3 years.
Therapy continue if gains are being made in attaining
ambulation.
Treatment…
Casting..
Short leg casts are applied with extended toe plates, careful
molding of the heel and metatarsal head control.
For a period of time varies but usually a minimum of 6
weeks. and is followed by the use of orthoses.
There is a limited role for casting in patients with cerebral
palsy.
Orthoses..
Can be helpful in improving gait in ambulatory patient with
cerebral palsy.
Ankle-foot orthoses are most commonly prescribed to assist
the child with positioning of the ankle and foot during gait.
Ankle Foot Orthoses (AFO)
Cerebral palsy
The upper limb
surgery
The upper limb
The basic goals can be achieved with operative treatment of upper
limb..
I.
Improvement in function.
II.
Improvement in appearance.
III.
Facilitates nursing care in children who are unable to care for
them selves because of more severe involvement.
The major surgical methods…

Lengthening of a tight musclotendinous unit.

Augmenting a weak muscle by tendon transfer.

Arthrodesis in the older children.
The upper limb..
Non-surgical treatment..
Directed towards..
 Preventing of contracture.
 Splinting for positional improvement.
 Hand therapy to improve dexterity.
 Sensory reeducation.
 Muscle relaxants( as Baclofen or Botox) affect in decreasing spasticity.
Surgical treatment..
Most procedures attempt to restore balance by combination of soft tissue
releases and tendon transfer, or by arthrodesis where soft tissue
procedures are inadequate.
The typical posture of spastic upper limb is…elbow, wrist and fingers
flexion, and forearm pronation.
Flexed wrist and hand
with pronation of the forearm
Elbow flexion contracture
Occurs usually in the globally involved child.
Shoulder adduction contracture may be present
Severe elbow flexion contracture can be relieved
by…



i.
ii.
iii.
iv.

Release of the lacertus fibrosis.
Z-lengthening of biceps tendon.
Lengthening of brachialis tendon.
Proximal origin of brachoradialis m. can be released.
Loss of some active flexion may happened.
Mital elbow flexion release
Forearm pronation

Develops insidiously, and with growth,
causes a rotational deformity of radius.

The release or rerouting of the pronatore
tendon is the option for correction when the
fore arm is passively correctable.
Fractional lengthening
of pronator teres
at its insertion
to the radius.
Wrist and fingers flexion

The goal of surgical procedure on the wrist and fingers is to allow
the fingers to open with wrist flexion for release, and to close with
wrist extension for grasp.

The lengthening of the wrist flexors, flexor carpi ulnaris at the
intramuscular level, Z- lengthening of flexor carpi radialis, release
of palmaris longus and super fascia and with fractional
lengthening of the flexor profundus. all that will allow the wrist to
be brought into extended position.

The extensor carpi ulnaris is the preferred tendon to transfer into
the extensor carpi radialis brevis.

Severe deformity: especially in non functional hand, wrist
arthrodesis is a solution for hygiene and care problems.
The thumb



Thumb-in-palm deformity is common in cerebral palsy patients.
The deforming forces are: adductor pollicis and all the intrinsic
muscles.
The approach is to release contracted soft tissue and then
augment weak extensors and abductors by…
1. Simple release of the contracture when child demonstrates
active thumb interphalangeal extension and a palpable extensor
pollicis longus.
2. Release of the origins of the thenar musculature, and the two
heads of adductor pollicis.
3. Release of the first dorsal interosseous fascia with release of the
thumb-index web space.
Release of the origins of intrinsic muscles
acting on thumb.
Deformities of thumb in cerebral palsy
Cerebral palsy
The lower limb
surgery
Foot surgery
Foot surgery
Equinus

It is an increased plantar flexion due to a plantar flexion
contracture or dynamic plantar flexion due to over activity of the
gastrocsoleus during gait.

Toe-walking patients must be considered as two different
groups:
i.
equinus patients.
ii.
as a consequence of crouch at the hip and knee with natural
ankle.

Cerebral palsy must be differentiated from:
A. Idiopathic toe walking as a congenital short Achilles tendon
B. Muscular dystrophy (as Duchenn’s)produces toe walking.
Equinus..
Clinical examination..
Of the child with equinus due to cerebral palsy shows
inability to fully dorsiflex the ankle.

The Silverskiold test:
If the ankle can be passively dorsiflexed with the knee
bent to 90 deg. but cannot be dorsiflexed with the
knee extended.. It’s felt that the gastrocnemius is
tight, but the soleus is not contracted.


This test is used to determine which type of surgical
lengthening to perform.
The Silverskiold test
Equinus…
Leads to…
 Gait is less efficient.
 Foot drop results if anterior tibialis is unable to lift
the foot to natural during swing phase.
 Genu recurvatum is seen.
 Valgus positioning of the hind foot.
 Calcaneus is actually in equinus.
 Pain and callosities result over the head of talus.
 Hallux valgus can develop.
Surgical treatment of equinus
It is selective lengthening of the Achilles
tendon or the gastrocnemius.
 It is believed that a gastrocnemius recession
should be performed when Silverskiold test
(performed under anesthesia) is positive and
dynamic EMG shows more abnormality of the
gastrocnemius than the soleus during gait.

Surgical treatment of equinus..

1.
2.
3.
Achilles tendon
lengthening..
Casting is necessary.

Gastrocnemius recession..
1.
Can be done per
cutanously.
3.
Preserve push-off power.
Immobilization is minimized
following operation.
Open methods.
2.
4.
5.
Almost no risk of over
correction.
Greater recurrence rate (up
to 48%)
Gastrocnemius recession
techniques
1.
2.
3.
Vulpius technique..
Strayer procedure
Baker technique.. (tongue-in-groove)
Vulpius technique..
Strayer procedure
Baker technique
Achilles tendon lengthening
techniques
1.
2.
Open technique.. with Z-fashion lengthening
Per cutaneous techniques..
White.. Two-cut technique.
Hoke.. Three-cut technique.
Z lengthening of Achilles Tendon
Hoke per cutaneous Achilles T.
lengthening
Equino varus deformity


Muscle imbalance in which the invertors of the foot over power
the evertors. with the gastrocnemius contributes equinus.
Surgery is indicated to..
1. Improve foot contact.
2. Relieve pain.
3. Relieve skin changes.

Tendon surgery can be done if the foot can passively corrected
with manipulation to the natural position.

Bony surgery is necessary when the deformity is stiff and
cannot be manipulated into a plantigrade position foot.
Equinovarus deformity..
The confusion test:
The patient flexes the hip against resistance..
If the supination of the forefoot is seen, the a.tibialis
is contributing to equinovarus deformity..
When dorsiflex is seen without supination, the
deformity is less likely to respond to surgery on
the a.tibialis.
Equinovarus surgery
p.tibialis tendon lengthening
Usually done in conjunction with Achilles
tendon lengthening.
It is done In young patients with mild varus
with equinus.
Can be performed as intramuscular
lengthening or as tendon Z lengthening.
Complications..




I.
II.
Recurrence of the deformity.
Development of postoperative valgus.
Equinovarus surgery
Transfer of the p.tibialis tendon to the
dorsum
It is not a preferred procedure because of its
disastrous complications: heel valgus in 68%
of patients.
Equinovarus surgery
Split p.tibialis tendon transfer
Popularized by Kaufer& Green.
 It is one of the most common procedures for
equinovarus deformity treatment.
 The posterior one-half of the p.tibialis tendon
is rerouted posterior to tibia and woven into
the peroneus brevis tendon.

Kaufer split transfer of tibialis posterior tendon
Kaufer split transfer of tibialis posterior tendon
Equinovarus surgery
Split a.tibialis tendon transfer
The lateral one-half of a.tibialis is detached
from it’s insertion.
 Passed beneath the extensor retinaculum.
 Inserted through a bone tunnel into the
cuboid.
 Foot is positioned in 5-10 deg. of dorsiflexion.
 Known as the Rancho procedure when done
in combination with p.tibialis lengthening.

Hoffer of split transfer of tibialis anterior tendon
Equinovarus surgery
Bony surgery


Its done where the varus deformity is fixed.. and the
p.tibialis tendon lengthening would not provide
correction.
Heel varus will respond to calcaneal osteotomy.

If the deformity is severe, and with rigid component
of mid foot supination… Triple arthrodesis should
be performed.

Even with bony procedures, muscle imbalance must
be corrected.
Dwyer closing wedge osteotomy of calcaneus for varus heel
Pes valgus




Occurs in up to 25% of patients with cerebral palsy.
and most common in older diplegic or quadriplegic
patients.
Can be caused by spastic peroneal muscles,
weakness of the p.tibialis and a tight gastrocsoleus.
Radiographs should be obtained in standing position
for the foot and ankle.
Conservative treatment should vigorously pursued..
shoe inserts and orthoses may be adequate to relive
pain and avoiding surgery.
Pes valgus
Surgical treatment of Pes valgus
Bony surgery is the only predictable
alternative for full and lasting correction.
Surgical options are…


I.
II.
III.
IV.
The Grice extra- articular arthrodesis.
Lateral column (calcaneal neck) lengthening.
Calcaneal osteotomy.
Triple arthrodesis.
Surgical treatment of Pes valgus
Grice extra- articular arthrodesis



First described by Grice in 1952 for correcting Pes valgus in young polio
patients in the age of 4-12 yrs.
Then widely used for correction of Pes valgus in children with cerebral palsy.
Satisfactory results reported in 79% of patients.

A graft is propped into the sinus tarsi laterally to support the plantar flexed talus
and correcting valgus of subtalar joint.

Advantage: does not interfere with the growth of tarsal bones.
Failures are due to:

1.
2.
3.
4.
5.

Persistent valgus.
Overcorrection into varus.
Ankle valgus.
Graft slippage.
Graft nonunion.
Modifications to the original procedure:


Fibular graft was changed to iliac crest graft.
Using internal fixation to keep the position of the subtalar joint in combination with
cancellous iliac crest graft.
Grice extra- articular arthrodesis
Dennyson and Fulford technique of
Extra articular subtalar arthrodesis
Surgical treatment of Pes valgus
Lateral column lengthening

First described by Evans.

Correction is achieved by lengthening the
calcaneus, and therefore the lateral column of foot,
effecting tightening of plantar fascia and reduction of
the lapsed talonavicular joint.

Achilles tendon and peroneal tendons must be
lengthened.
Surgical treatment of Pes valgus
calcaneal osteotomy
Advantage: preserve joint motion of sub talar
joint.
Results have been very good.
Contraindications: severe rigid valgus
deformity.
Baker and Hill osteotomy of calcaneus to correct heel valgus
Medial displacement of calcaneus for hind foot valgus
Surgical treatment of Pes valgus
Triple Arthrodesis
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
Treatment of choice for rigid symptomatic Pes valgus in
adolescent with cerebral palsy.
Resecting the subtalar, calcaneocuboid, talonavicular joints.
Indications:
1. Pain
2. Skin ulceration over the talar head.
3. Deformity interfering with ambulation in child with deformity not
amenable to osteotomy.
Satisfactory outcomes are found when deformity is well
corrected.
Degenerative changes have been documented in the ankle joint
at an average of 18yrs.following arthrodesis in 43% of the
pediatric population.
Triple arthrodesis for Pes valgus treatment
Ankle valgus
Valgus alignment of the ankle develops in patients with
neuromuscular diseases.
Radiographs of ankle in standing should be obtained before
surgical correction of Pes valgus.



I.
II.


Surgical correction is done by..
Hemiepiphysiodesis of the distal medial tibia (medial screw,
staples or open epiphysiodesis)
Osteotomy
Osteotomy is useful when immediate correction is desired.
A Closing wedge osteotomy of distal tibia, combined with
distal fibular osteotomy is performed.
Hind foot valgus
Ankle valgus
Subtalar
arthrodesis
Medial
Epiphysiodesis
with screw
technique
Dorsal bunion

It is a rare deformity.
The first metatarsal head is elevated, but the great
toe is plantar flexed.

Surgical rebalance depends on…





Transfer of the flexor tendon to the extensor.
Or flexor tenotomy.
Or by transferring of the flexor hallucis brevis to the
metatarsal neck
Or by all that in combination with closing wedge plantar
flexion osteotomy of first metatarsal.
Hallux valgus




Develops in cerebral palsy patients in response to a Equino valgus deformity of
the hind foot.
There is a progressive eversion and abduction of foot because of peroneus
longus is spastic.
The toe is pushed laterally as weight is borne by the everted foot.
The big toe comes to lie beneath the second toe, and the first metatarsal head
becomes uncovered and painful bunion develops.

When this deformity is mild, surgical treatment of Pes valgus will halt the
progression of toe deformity.

Bleck& Goldner described soft tissue realignment including:
Release of the adductor hallucis t. and lateral capsulotomy of the first metatarsophalangeal
joint. combined with first metatarsal and proximal phalangeal osteotomy.

McKeveer technique:

First metatarsophalangeal fusion.
That led to better results with less recurrence than soft tissue realignment.

Preferred position for fusion is 15-25 deg. Of dorsiflexion and slight valgus.

Hallux valgus in 14 yrs. Old girl with cerebral palsy.
Treated with metatarsophalangeal fusion.
Knee surgery
Knee surgery
Consists of…
 Hamstring lengthening.
 Rectus femoris transfer.
Hamstring lengthening
The hamstrings are nearly always affected in cerebral palsy patients,
and tight hamstrings lead to crouch gait.
Hamstrings cross two joints, at the hip they serve as extensors, and at
the knee they serve as flexors.
The popliteal angle measures the hamstrings spasticity and values
greater than 50 degrees are considered abnormal in children of
4yrs and older. (normal is about 26 degs.)
Fixed knee flexion contracture develops in severe hamstring
contracture.
That leads to disappointing results following hamstring lengthening.
The Egger’s procedure has been historically used for the correction
of spasticity in the hamstrings and crouch knee, but genu
recurvatum was a frequent complication.
Holt’s method of determining hamstring contracture
Method of determining
hamstring tautness
Fixed knee flexion in a teenager
boy with spastic quadriplegia
Egger’s transfer of
hamstrings to femoral
condyles.
Hamstring lengthening..
Surgical lengthening of the distal hamstring is now the preferred
surgical treatment for crouch knee gait and is often performed in
combination with other soft tissue procedures.



With intramuscular aponeurotic lengthening of semimembranous,
a Z-lengthening of semitendonosus
and either tenotomy or Z-lengthening of the gracilis at a level just
proximal to the knee.
An adequate lengthening has been accomplished (intraoperatively)
when the popliteal angle is reduced to around 20 degs.
Greatest improvements in the knee flexor contracture are seen within
1 year following surgery.
Rectus femoris transfer
Spasticity in the rectus femoris is tested by the Duncan Ely test.
The surgical treatment for stiff knee gait and inability to flex the knee
in swing phase is a rectus femoris transfer.
Often performed simultaneously with hamstring lengthening and other
soft tissue procedures.
Current indications for distal hamstring lengthening with rectus
femoris transfer are:
1.
2.
3.
4.
5.
6.
Significant crouch gait during stance phase with limited knee extension
at midstance.
Increased popliteal angle and positive rectus femoris grab on clinical
examination.
If EMG shows activity in the rectus femoris during swing phase.
In the case of sufficient hip pull-off power generation at late stance
phase.
For velocity greater than 60% of normal.
If there are no significant rotational abnormalities of the hip that
interfere with gait.
The Duncan Ely
test
Rotational osteotomies
Spasticity in the lower extremities leads overtime to the development
of rotational abnormalities in the femur and tibia.
Persistent femoral anteversion is present in patients with spastic
diplegia, and in some patients with severe spastic hemiplegia.
Physical examination shows increased internal rotation and decreased
external rotation of the hip.
Overtime, compensatory external rotation of the tibia develops.
Internal tibial torsion may be present in children with cerebral palsy,
specifically patients with spastic hemiplegia.
This torsion can be quantified by examining the bimalleolar angle.
Rotational osteotomies..
The best correction of rotational malalignment of the lower extremity
is achieved by derotational osteotomies.
Femoral anteversion is treated with inter or subtrochanteric level
osteotomy or at the supracondylar level.
In the case of tibial rotational deformities, surgical correction should
be performed at the distal level.
Distal femoral osteotomy
for anteversion
Bilateral rotational osteotomies
(tibial torsion)
Hip surgery
Hip surgery
Hip surgery in cerebral palsy can be divided
into three areas:
Correction of hip flexion contracture.
 Correction of increased hip adduction during
gait or scissoring.
 Surgery to treat the subluxating or dislocating
hip.

Hip flexion contracture
surgery
Hip flexion contractures are found most commonly in patients with spastic
diplegia and spastic quadriplegia.
Flexion contracture is due to increased tone in the hip flexors (primarily the
iliopsoas) and relative weakness of the hip extensors (such as the
gluteal muscles)
The contracture is identified during the physical examination by performing
the Thomas and Staheli maneuvers.
The sacro-femoral angle is used to objectively quantify of the hip flexion
contracture.
Normally should be between 45-65 degs.
Hip flexion contracture
surgery..
The surgery in a walking child is done to improve the hip flexion
contracture, and to prevent increasing hip flexion and anterior pelvic tilt
when hamstring lengthening is performed.
The recommended procedure is a psoas tenotomy done over the pelvic
brim.
Release of the iliopsoas tendon off the lesser trochanter should not be
done in ambulatory patients.
Bleck advised against simply releasing the iliopsoas, and suggested
attaching the distal iliopsoas tendon anteriorly into the hip capsule.
Thomas test
Staheli test
The sacro-femoral
angle
Adduction contracture surgery
Spasticity in the adductor muscles in cerebral palsy results in a narrow
base of gait and scissoring.
Over time, the untreated adduction contractures, when combined with
hip flexion contracture lead to progressive hip subluxation and
possible dislocation.
The muscles leading to the adduction contracture are:
I.
The adductor longus
II.
Adductor brevis
III.
Adductor magnus
IV.
gracilis
V.
Occasionally the pectineus
Clinical examination reveals inability to abduct the hips in flexion and
in extension.
Increased femoral anteversion when combined with crouch at the knee
can produce the appearance of scissoring which termed as
pseudo adduction.
Adduction contracture
surgery..
Adductor surgery will be ineffective in improving the child’s
ability to walk when the narrow base of gait is secondary to
pseudo adduction.
Surgery to improve adduction contracture is limited to adductor
release, with or without obturator neurectomy, and posterior
adduction transfer.
Adduction release is commonly performed in the young child
with cerebral palsy who is able to stand with support but has
difficulty walking because of scissoring.
And its advantage is that it is a simple and quick procedure
resulting an increased abduction and improved scissoring.
Adduction contracture
surgery…
Banks and green described this procedure by..
 Detaching the adductor longus tendon from its origin on the
superior pubic ramus, often along with at least part of the
add.brevis and the gracilis tendons.
 The add.magnus is not released.
 Anterior branch of obturator neurectomy should not be performed.
Further surgery is necessary with growth in 10-37% of all children who
undergo adductor release.
Perry advised a procedure in which the add.longus, add.brevis, and
gracilis tendons are transferred from the pubic ramus to the
ischium.
In the Beals modified adductor transfer, the adductor longus and brevis
are sutured into the lengthened gracilis, which remains attached to
its origin.
Posterior transfer of hip adductors to
ischium
Hip subluxation/dislocation
surgery








hip dysplasia or instability is a common problem occurring in about
21% of cerebral palsy patients.
Reports shows a prevalence of subluxation or dislocation ranging
from 3 to 47% in cerebral palsy patients.
Patients with spastic hemiplegia rarely develop hip dysplasia and
dislocation.
Patients with spastic diplegia are at increased risk.
Patients with spastic quadriplegia have the highest rate of hip
instability.
The mean age at which patients with cerebral palsy present with
subluxation or dislocation is 7 yrs.
Hip subluxation develops in response to muscle imbalance.
Subluxation develops gradually, with increasing lateralization and
proximal migration of the femoral head with respect to the
acetabulum.
Hip subluxation/dislocation
surgery..





Bony deformity occurs in response to the spasticity.
The normal remodeling of the femoral anteversion seen in
normal young child does not occur in patients with cerebral
palsy, and anteversion persists into adulthood.
The neck-shaft angle becomes increased as coxa valga
develops.
Acetabular changes occur as the hip subluxates,with an
increased Acetabular angle and erosion of the lateral lip of
acetabulum
Finally, changes in the shape of femoral head takes place,
with superolateral and superomedial notching.
Hip subluxation/dislocation
surgery…
On physical examination: hip subluxation or dislocation can be
suspected with the presence of:
A.
Loss of range of motion.
B.
Abduction will be limited to less than 30 degs.
C.
A hip flexion contracture is presence.
D.
Increased internal rotation and,
E.
Decreased external rotation of the hip.
F.
When a unilateral dislocation is present, a positive Galleazzi sign
will be obvious.
Radiographically, the diagnosis is confirmed..
1.
Subtle break in Shenton’s line and a mild uncovering of the most
lateral aspect of the femoral head.
2.
Reimers’ migration index.
3.
Elevated acetabular index.
4.
The neck-shaft angle is increased.
Hip subluxation/dislocation
surgery….
Treatment of hip dysplasia has the following goals:
 To provide a painless hip that allows stable sitting and positioning in
the non ambulatory patients.
 To reduce the hip fully so that ambulation can continue without
groin or hip pain in patients who can walk.
 For the hip that is subluxated, surgery is done to prevent
dislocation.
The first question to be answered is, does treatment make a
difference in hip subluxation and dislocation in the child with
cerebral palsy?
Several studies shows great controversy with differing results.
Bleck advocates surgical reduction of hip in cerebral palsy, stating that
one-third of patients with hip dislocation develop pain.
Hip subluxation/dislocation
surgery…..
The next question to be asked is, does hip subluxation or
dislocation lead to scoliosis?
The conclusion is that there is a strong tendency for unilateral
hip subluxation to occur in conjunction with pelvic obliquity,
with most dislocations on the high side of pelvis.
Surgical treatment is divided into three phases:
I.
Soft tissue surgery for the hip at risk.
II.
Reduction and reconstruction of the subluxated or
dislocated hip.
III.
Salvage surgery for long standing painful dislocation.
Paralytic dislocation of L hip and scoliosis
Soft tissue release for
subluxation of the hip at risk
The hip at risk is defined as a hip that has significant adduction
and flexion contractures but minimal subluxation with a
migration index of less than 30%
The patients are 5 yrs. old or younger.
Surgical treatment is aimed at preventing dislocation of the hip.
Soft tissue release of contractures is indicated when abduction
range is less than 30 degs. and flexion contracture is more
than 45 degs.
The procedure consists of adductors release and iliopsoas
lengthening or release.
Soft tissue release for
subluxation of the hip at risk..
Out comes of the procedure are in general:
 The early results were promising.
 13% of hips treated had subluxated and there
where no dislocations.
 Dislocations was prevented in 80%
 83%of hips with preoperative migration index of
less than 40% that were treated by adductor
release remained stable.
 Hips with a preoperative migration index of
greater than 50% had poorer results.
Soft tissue release for
subluxation of the hip at risk…
Iliopsoas transfer is not a recommended as a part
of surgical treatment of hip instability in cerebral
palsy patients.
The current indications for adductor and iliopsoas
soft tissue release in patients with hips at risk for
dislocation include:



Adduction contractures in a young child, no older than
5yrs.
With limited abduction of 30 degs. or less.
And a migration index of not more than 30%
Femoral osteotomy
The most frequently performed procedure in the treatment of
more significant hip subluxation is a femoral varus
derotation osteotomy (VDRO).
An osteotomy is performed at the intertrochanteric level, usually
accompanied by a closing wedge taken medially and/or
femoral shortening, and the femur is fixed in an increased
amount of varus with internal fixation.
The two most frequently used plants for internal fixation are..
 Hip screw and side plate.
 90 degs. blade plate.
Femoral osteotomy..
Release of soft tissue contracture must also be done to balance the
forces across the hip.
Hoffer concluded that VDRO is a good procedure for hip subluxation,
but is inadequate to treat the dislocated hip in cerebral palsy..
Other studies advocate pelvic osteotomy in addition to VDRO if the
preoperative migration index is greater than 70%
No significant remodeling into valgus can be expected in patients
operated on the age 8yrs or older.
Complications for femoral VDRO…





Recurrent dysplasia.
Loss of fixation.
Fractures.
Delayed union and nonunion are rare.
Heterotopic ossification can result.
R hip subluxation+ adductor release +VDRO
Combined femoral varus and
pelvic osteotomies
In cases in which a femoral VDRO does not provide adequate
coverage or stability to the hip, pelvic osteotomy should be
performed.
The pelvic osteotomies used are..
 Re directional osteotomies (such as the Steel an Salter
procedures)
 Osteotomies that reshape the acetabulum (such as Pemberton and
Dega osteotomies)
 Salvage osteotomies that increase the area of the acetabulum with
non articular cartilage (such as the Chiari osteotomy and the shelf
augmentation procedure.
The two pelvic procedures with the longest historical use in patients
with cerebral palsy are the Chiari osteotomy and the shelf
augmentation procedure..
Combined femoral varus and
pelvic osteotomies..
The Chiari osteotomy.
This osteotomy is performed by making a
horizontal osteotomy from the sciatic notch to a
point just at the superolateral margin of the
acetabulum. and the osteotomy is displaced
medially so that the hip capsule lies over the
lateral bony surface of the ilium.
Indications for Chiari osteotomy were:


Presence of severe subluxation or,
The presence of moderate incongruity on arthrography
following the femoral osteotomy.
Paralytic dislocation of R hip in cerebral
palsy+ open reduction +femoral shortening
+Chiari osteotomy
Combined femoral varus and
pelvic osteotomies…
the shelf acetabular augmentation procedure.
As described by Staheli :
A notch is made in the outer wall of the ilium just at the margin
of the acetabulum, and a cancellous and cortico-cancellous
strips of iliac crest are wedged into this notch above the hip
capsule.
This procedure is indicated in a hip in which spherical
congruency cannot be achieved. and also helpful in hips in
which there is global acetabular deficiency and a small
articular surface.
Studies of the results in cerebral palsy are encouraging, with hip
stability obtained in 83-95% of patients.
This procedure should not be performed in very young patients.
Combined femoral varus and
pelvic osteotomies….
The Dega osteotomy.
A third pelvic osteotomy that is of particular benefit in hip dysplasia
secondary to cerebral palsy.
As described by Mubarak;
1.
2.
3.
4.
5.
The osteotomy extends through the outer table of the ilium from the
anterior iliac spine to the sciatic notch.
A bicortical osteotomy is performed only at the anterior-inferior iliac
spine, and the inner table of ilium is not cut.
The lateral osteotomy is extended to the triradiate cartilage under
fluoroscopic guidance.
The osteotomy is pried down laterally and posteriorly.
Wedges of bone graft prop the osteotomy open.
A prerequisite for Dega osteotomy is an open triradiate cartilage.
Dega osteotomy allowed excellent correction of the superior and
lateral deficiency seen preoperatively.
A similar osteotomy is used combined with a shortening femoral VDRO
and aggressive muscle release.
Combined femoral varus and
pelvic osteotomies…..
The indications for this combined procedure are:
 Failure of soft tissue release in a child less than 8yrs old.
 Subluxation, defined as a migration index greater than 40%
in children older than 8yrs.
 A recent hip dislocation (within 2yrs.)
 A painful subluxated or dislocated hip without significant
femoral head deformity.
The benefit of Chiari, shelf augmentation, and Dega procedures
is that they provide coverage posteriorly and laterally and
improve the migration percentage and the CE angle of
Weiberg.
The Salter’s innominate osteotomy is not to be used in spastic
dislocations.
Surgical treatment of the non
reconstructable hip
Surgical reduction of the dislocated hip in patients with cerebral palsy should
be limited to those children who do not have significant bony changes in
the femoral head.
In the presence of arthritic changes and severe erosion of the femoral head, it
is clear that the hip cannot be reconstructed.
The indications for surgery in this group of patients include:
1)
2)
3)
Hip pain
Inability to sit in a modified wheel chair.
Difficulty with perineal hygiene duo to contractures
There are 4 surgical options:

Proximal femoral resection.

Valgus osteotomy of proximal femur.

Hip arthrodesis.

Total hip arthroplasty.
Proximal femoral resection
interposition arthroplasty
Described for the treatment of painful dislocations of the hip in
non ambulatory patients…
 The abductors are sharply detached from the greater
trochanter.
 An osteotomy is made across the level of 3cm distal to the
lesser trochanter.
 The iliopsoas tendon is transected.
 The hip capsule is detached and sewn shut following
removal of the proximal femur, to cover the acetabulum.
 The quadricaps muscle is sewn over the end of the femoral
shaft.
 The abductors are interposed between the acetabulum and
the femur.
Patients is then placed in traction for 3-6 weeks.
Proximal femoral resection
Valgus osteotomy of the
proximal femur
Performed to allow the thigh to come out into
abduction, allowing perineal hygiene.
The femoral head is repositioned farther
lateral from the acetabulum, so that the
rubbing between the pelvis and the head is
lessened.
Valgus osteotomy
Anterior hip dislocation
Hip arthrodesis
Surgical fusion of the hip is been performed in
patients with painful dislocations of the hip due to
cerebral palsy.
The desired position of fusion in non ambulatory
patients is 50 degs of flexion and 10 degs of
abduction.
Root used a combined intra and extra articular
technique, with subtrochanteric osteotomy of the
femur o allow positioning of the leg.
Total hip arthroplasty
Root has been the greatest advocate of THA in patients with
cerebral palsy.
The ideal candidate for joint replacement is an adult with
cerebral palsy who is able to walk, stand, or transfer.
Patients should not have coexisting pelvic obliquity or scoliosis.
Technical considerations are…
 The need to flex the acetabular component to provide
posterior stability in sitting patients.
 The frequent loss of acetabular bone stock superolaterally,
which requires bone grafting.
Anterior dislocation of the hip
Occurs much less frequently than the posterolateral type.
Two groups of children are at great risk:
1.
2.
Patients who have excessive adductors and hip flexors release, leading to
extension and abduction contracture.
Children with severe neurological involvement with extension posturing.
Symptoms: inability to sit in wheelchair due to extension contracture. and pain
in half of those patients.
On Physical examination.. the femoral head is palpable in the anterior groin.
and the hip flexion is limited.
In the radiograph, the hip may appear reduced as it lies anterior to the
acetabulum.
Treatment:

Aggressive muscle release of proximal hamstrings, and

If the patient is abducted, the abductors and short external rotators must be
included.

Varus shortening osteotomy of the femur is recommended, in conjunction
with acetabular osteotomy to gain anterior coverage.
The Pemberton osteotomy is useful here.
Cerebral palsy
Spinal deformity
Scoliosis..
Spondylosis..
scoliosis






Affecting between 25-68% of patients with cerebral palsy.
Incidence is highest in non ambulatory patients, and who have total
body involvement.
Patients with spasticity are at high risk, compared to other
movement disorders.
The usual curve pattern is a long sweeping curve that extends to
the pelvis. with the apex of the curve at the thoracolumbar junction.
Rotation accompanies the coronal plane curvature.
Scoliosis leads to difficulty in sitting, and in using wheel chair. with:
pressure sores on ischium teberosities, and a hand dependent
sitter.
Scoliosis..
Indications for spinal fusion are:



Curves of more than 50 degs in ambulatory patients.
Progressive curves of more than 50 degs in patients who are communicative and aware of
their surroundings.
Curves that interfere with seating and nursing in patients whose families desire surgical
correction.
Segmental fixation is preferred.
The role in scoliosis due to cerebral palsy is to instrument and fuse long.
The fusion extends from T2 to the pelvis in non ambulatory patients, and to the lower
lumbar spine in those who walk.
The Luque technique, which uses sublaminar wires at each level…
Distributes the corrective forces equally through the spine.
Allows greater correction and better sagital contouring,
And there is less loss of fixation.
Fusion of the spine to the pelvis is accomplished using the Galveston technique.
Scoliosis…
The Dunn McCarthy technique is suitable for many cerebral palsy
patients.
Two S-shaped rods are placed over the sacral ala. with upgiong
laminar hooks or pedicle screws placed more proximally. then
segmental fixation is completed.
The advantage is that the sacro iliac joint is not crossed, which leads
to less movement and loosening over time.
The anterior release, discectomy and fusion are recommended in:
 Younger patients with open triradiate cartilages.
 Severe, stiff curves.
 Curves over 70 degs.
 In patients which a stretch spine radiograph shows lack of
correction of pelvic obliquity.
Scoliosis in a 11yrs. old boy (angle of
87degs)
Using the Luque rods and sublaminar
wires with the Galveston technique.
Scoliosis in a 13 yrs. old girl (angle of 79
degs.)
Using the Dunn McCarthy technique.
Cervical spine spondylosis
Develops in patient with athetoid type cerebral palsy.
Symptoms: develop in late adolescence and early adulthood…
Neck pain, arm pain.
Weakness.
Decreased sensation in arms and legs on examination.
Deterioration in gait.
Treatment: surgical, by anterior inter body fusion and
postoperative immobilization with Halo vest. Or by combined
anterior and posterior spinal fusion.
Rhizotomy
Selective dorsal rhizotomy in which a percentage of the dorsal roots are
severed at the level of cauda equina.
Spasticity is improved by reducing the stimulatory inputs from the muscle
spindles of the lower extremities that arrive via afferent fibers in the dorsal
roots.
Usually 25-50% of the posterior nerve rootlets from L2 to S2 are divided.
The rate of good results following rhizotomy depends on proper patients
selection…

Candidates are younger than 8yrs.

Must have purely spastic type.

Should have no fixed contracture.

Must be able to ambulate without relying on spasticity for strength.

There is no weakness in the antigravity muscles or trunk musculature.

Must have supportive families and be able to cooperate with postoperative
physical therapy.
Cerebral palsy
Fractures
Fractures
Bone mineral density is decreased in patients with cerebral palsy.
Low levels of vit.D have been documented in up to 42% of children
with severe cerebral palsy.
Up to 74% of fractures occur in the femur ,particularly at the
supracondylar level.
Treatment of osteopenia:
A. Vit.D supplementation.
B. Biphosphonate.
Treatment of fractures:


Usually by cast immobilization.
Internal fixation in femoral shaft fractures.
Thank you all…
THE END
22nd-Aug-2006
MoKazem.com
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Dr. Muayad Kadhim
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