lower extremity orthopedic surgeries - rady children's ... · pdf filelower extremity...
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Lower Extremity Orthopedic Surgery
in Cerebral PalsyHank Chambers, MD
Rady Children’s Hospital - San Diego
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Indications• Fixed contracture• Joint dislocations• Shoe wear problems• Pain• Perineal hygiene problems
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What can Orthopedic Surgery Offer?
• Lengthen tendons• Transfer tendons• Relocate joints• Rotate bones• Fuse joints
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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
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The Diving Syndrome
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Timing of Surgery
Boyd, Graham et al Eur J Neur 6(supp 4), 1999
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• Soft tissue contractures• Bony abnormalities
– Morphology– Rotation
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Spine Problems• Scoliosis• Spondylolisthesis
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Hip Adduction Deformity
• Open vs percutaneous lengthening of adductors
• ? Obturator neurectomy
Canale and Beaty Operative Pediatric Orthopedics 1991
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Adductor Lengthening
Obturator Neurectomy
Canale and BeatyOperative Pediatric Orthopedics
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Hip Flexion Deformity
• Usually caused by contracture of the iliopsoas muscle
• Sartorius, rectus femoris and tensor fascia femoris muscle can also contribute
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Treatment of Hip Flexion Contractures
Canale and Beaty Operative Pediatric Orthopedics 1991
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Psoas lengthening at the Pelvic Brim
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Hip Subluxation & Dislocation
Hip Subluxation
Acetabular Dysplasia
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Hip Subluxation & Dislocation
Indications for Treatment:• Hip subluxation in any condition• Pain• Loss of sitting ability
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Proximal Femoral Varus Derotational Osteotomies
Indications for surgery:
‘d valgus ‘d femoral anteversion
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Acetabular Dysplasia• Usually posterior dysplasia
AnteriorPosterior Mid-superior
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Treatment of Acetabular Dysplasia
Periacetabular Osteotomy, Open Reduction and VDRO
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San Diego Approach to Hip Dislocation
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Salvage Procedure for Hip Dysplasia
• Interposition arthroplasty
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Problems at the Knee• Crouch gait• Jump gait• Stiff knee gait• Recurvatum gait
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Crouch Gait
• Increased hip flexion• Increased knee flexion• Increased ankle dorsiflexion
(calcaneous)• Usually iatrogenic
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Patella Alta
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Jump Gait• In di or hemiplegia• Increased hip
flexion• Increased knee
flexion• Increased ankle
plantar flexion
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Hamstring Lengthening
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Stiff Knee Gait• Manifest by swing phase knee stiffness• Leads to problems of foot clearance• Compensatory mechanisms include
– Hip Circumduction– External Rotation– Contralateral vaulting
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Rectus Femoris Transfer
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Recurvatum Gait• Usually iatrogenic• Difficult to treat surgically• Often need long leg braces
(KAFO with the ankle in dorsiflexion)
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KNEE PROBLEMS IN ADULTS WITH CEREBRAL
PALSY
• Patellofemoral arthritis• Patellar malalignment
syndrome• Meniscal tear• Cruciate ligament tears
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Rotational Abnormalities
• “Lever Arm Syndrome”– Increased Femoral Anteversion– Increased internal or external tibial torsion– “malignant malalignment” syndrome– Patellar subluxation/dislocation– Foot valgus
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Treatment• Femoral osteotomies
– Proximal– Distal
• ? Gluteus medius transfer• Tibial derotational osteotomies• Correction of valgus in foot
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Problems at the Foot & Ankle
• Equinus• Calcaneous• Varus• Valgus• Bunion
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Treatment Options for Equinus
• Lengthening of the fascia (recession)– Strayer– Baker– Vulpius– Baumann
• Lengthening of the Tendoachilles
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Equinus
Gastrocnemius RecessionStrayer or Vulpius
OpenTendoachillesLengthening
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Calcaneous• Usually iatrogenic
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Treatment Options for Calcaneous
Surgical:Muscle transfer to heel
TA, TP, PL, PB, FDL, FHLHeel cord tenodesisOsteotomy of calcaneus
(can combine with muscle transfer)ObliqueCrescentic
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The Varus Foot
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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)
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Frost Tibialis Posterior Tendon Lengthening
Tibialis Posterior
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Split Posterior Tibialis Tendon Transfer
(SPOTT)
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Split Anterior Tibialis Tendon Transfer
(SPLATT)
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Valgus Foot• Common in diplegia &
quadriplegia
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Treatment Options for the Valgus Foot
• Peroneus Brevis Tendon Lengthening
• Calcaneal Lengthening• Calcaneal Sliding Osteotomy• Subtalar Arthrodesis• Triple Arthrodesis
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Peroneus Brevis Lengthening
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Subtalar Arthrodesis
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Subtalar Stapling
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Evan’s Calcaneal Lengthening
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Sliding Calcaneal Osteotomy
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Triple Arthrodesis
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Look for Ankle Valgus
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Bunion Deformities• Dorsal bunion• Hallux valgus
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Treatment• Standard bunion procedure• Arthrodesis
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