children’s healthcare of atlanta - choa.org/media/files/childrens/medical-professionals/... ·...

10/26/2017

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Comprehensive & Coordinated

Orthopaedic Management of

Children with CP

Robert Bruce, MD

Sayan De, MD

Children’s Healthcare of Atlanta

Objectives

• Understand varying levels of intervention are available to optimize function of children with neuromuscular disorders

• There are no protocols

• Understand that goals of surgical intervention rely on appropriate medical decision making based on upon a child’s comorbidities, function, and commitment by the multidisciplinary team

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It’s all about function

• But really…

– Tone

– Distribution of involvement

– Type of CP

– Presence of comorbidities

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Principles of Surgical Intervention

• ‘primum non nocere’

• Limit anesthetic risks/complications

• Minimize perioperative morbidity

• Maximize function

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Historical Perspective

• CP surgery was considered to be ‘birthday surgery’

• Increased number of and longer hospital stays

• Increased pain

• Increased exposure to anesthetic events

• Longer post-operative rehabilitation periods

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SEMLS

Single Event Multi-Level Surgery

• Benefits

– Single surgical intervention

– Bilateral surgery

– Single rehabilitation

– Single anesthetic risk

– Single episode of postoperative pain

– Allows for smaller ‘fine-tuning’ procedures if necessary

• Risks

– Potentially increased blood loss

– Potential increase in intensity of postoperative pain

– Longer anesthetic time during the single event

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SEMLS

Requires a multidisciplinary approach

– PT

– OT

– Rehab

– Neurology

– Orthotics/Prosthetics

– Nutrition/GI/Gen Surg

assess pre-op needs, post-op

plan of care for rehabilitation

and conditioning

Pre and post-operative tone

management

Mobility devices ready post-op

or during rehabilitation period

Help ensure proper wound

healing and maintenance of

nitrogen balance

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What does CHOA Offer?

Individually tailored plan of care/surgical interventions based upon the child’s needs and the expectations of

both patient and family.

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Areas of Orthopaedic Intervention

• Spine/Chest Wall

• Hip/Pelvis

• Knee

• Foot & Ankle

• Hand & Upper extremity

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Common Conditions

• Scoliosis

• Neuromuscular hip dysplasia

• Muscular spasticity

• Joint contractures

• Limb length inequality

• Planovalgus foot

• Cavovarus foot

• Equinus contracture

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Neuromuscular Hip Dysplasia

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Femur

Anteversion

Valgus

Progressive Deformity of Femoral Head

Dysplasia Subluxated Migration Index Dislocated

Acetabulum Shape / Head Coverage Sourcil Tear Drop


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26 Months

17 Months

Tone and growth


Neuromuscular Hip Dislocation

• Usually correlates with level of function

• Controversy of painful vs. non-painful dislocation

• What are the goals of management?

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Treatment Algorithm

Prevention

Reconstruction

Salvage

Children’s Healthcare of Atlanta 17

• 65 pts followed for minimum 8 years

• Soft tissue release was effective for long term prevention of hip dislocation in 67% of pts

• 2 predictors of favorable outcomes

– Spastic Diplegic

– Ability to walk


Prevention

• Soft tissue lengthening

– Adductor release

– Hip flexor release • Ambulatory: psoas only

– Hamstring release • If popliteal angle greater

than 45 deg

• Indications

– Under age 8 years

– Hip abduction < 30 deg

– MI 25-60%

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Reconstruction

• Indications

– Recommended above age 4 years

– For MI > 60% and dislocated hips

– Must not have degenerative changes

• Soft tissue lengthening

• Femoral osteotomy

– Varus derotational

– +/- shortening

• Pelvic osteotomy

– Lateral acetabuloplasty

– PAO if triradiate closed

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• 330 pts with CP followed for 7.1 years

• Success Rates

– II-94%

– III-49%

– IV-27%

– V-14%


Management of Gait Disturbances

Equinus

Stiff Knee

Jump Knee

Crouch

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My Approach…

1. Define pattern of involvement

2. Assess coronal plane deformity

3. Assess sagittal plane deformity

4. Assess axial plane deformity

**deformity is not always static**

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Hemiplegia

• Typical gait patterns

– Equinus • +/- LLD

• +/- HS

• Equinovarus +/- cavus

• Equinoplanovalgus

– Stiff Knee

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CORONAL SAGITTAL AXIAL TREATMENT

HIP ADDUCTION

LEG LENGTH

FLEXION INTERNAL

ROTATION

1. ADDUCTOR

LENGTHENING

2. FEMUR OR

3. PSOAS

LENGTHENING

4. DEROTATION

OSTEOTOMY

KNEE VALGUS

OR

VARUS

FLEXION

OR

EXTENSION

--------

1. DISTAL FEMUR

OSTEOTOMY

2. RECTUS

TRANSFER

3. HAMSTRING

LENGTHENING

FOOT/AN

KLE

VARUS CAVUS

ADDUCTION

TIBIAL TORSION

GS, MEDIAL

OSTEOTOMY + ST,

SPLPTT, +/- CALC

SLIDE, TIB OST

VALGUS PLANUS

ABDUCTION

TIBIAL TORSION

GS, LATERAL

OSTEOTOMY, +/-

CALC SLIDE, TIB OST 27

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CORONAL SAGITTAL AXIAL TREATMENT

HIP ADDUCTION

FLEXION

EXTENSION

---------

1. ADDUCTOR

LENGTHENING

2. PSOAS

LENGTHENING

3. HAMSTRING

LENGTHENING

4. DEROTATION

OSTEOTOMY

KNEE VALGUS

OR

VARUS

FLEXION

CONTRACTURE &

SPASTICITY

EXTENSOR LAG

ROTATION

1. DISTAL FEMUR

EXTENSION

OSTEOTOMY

2. PATELLAR

ADVANCEMENT

3. HAMSTRING

LENGTHENING

FOOT/AN

KLE

VARUS TRUE EQUINUS

CAVUS

ADDUCTION

TIBIAL TORSION

GS, MEDIAL

OSTEOTOMY + ST,

SPLPTT, +/- CALC

SLIDE, TIB OST

VALGUS APPARENT EQUINUS

PLANUS

ABDUCTION

TIBIAL TORSION

GS, LATERAL

OSTEOTOMY, +/-

CALC SLIDE, TIB OST 30

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Specific Indications

• Distal Femoral Extension Osteotomy plus Patellar Advancement

– Must be ambulatory!!!

– Severe crouch gait

– Knee flexion contracture 10-30 degrees

– Extensor Lag >10-20 degrees

(images removed due to copyright)

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Specific Indications

• When to touch the Hamstring…

– Knee flexion contractures less than 10 degrees

– Posterior pelvic tilt exists

– Avoid lateral hamstrings to prevent recurvatum

(images removed due to copyright)

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Percutaneous Tendon Lengthening

• Technique

• Indications

• Patient Selection

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Other Considerations

1. Presence of Growth Plates with Growth Remaining

– Guided Growth

– Staged Procedure

2. Beware the Hamstring

– Pelvic tilt

– Popliteal Angle

3. Beware the Achilles

– True Equinus vs. Apparent Equinus

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Summary

• These are challenging, complex kids

• Tone determines function

• Function determines intervention

• Tone still needs to be managed post-intervention

• Care of the CP child relies on a strong framework of care by a multidisciplinary team

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