orthopaedic selective spastic control surgery in cerebral palsy
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Transcript orthopaedic selective spastic control surgery in cerebral palsy
CEREBRAL PALSY
Thammanoon Srisaarn , MD.
Orthopaedic department
Pramongkutklao hospital
CEREBRAL PALSY
NON PROGRESSIVE (immature)BRAIN
LESION RESULTS IN MOTOR
IMPAIRMENT(may be other)
Uncertain
cause
Nearly drowning, infectious meningitis
Manifestration progress
CLASSIFICATION
PHYSIOLOGIC (Neuropathic)
GEOGRAPHIC (Anatomic)
PHYSIOLOGIC(NEUROPATHIC)
SPASTICITY(PYRAMIDAL SYSTEM)
ATHETOSIS(EXTRAPYRAMIDAL)
CHOREIFORM
DYSTONIA
HYPOTONIA
ATAXIC (CEREBELLUM)
MIXED
GEOGRAPHIC(ANATOMIC)
DIPLEGIA
HEMIPLEGIA
DOUBLE HEMIPLEGIA
PARAPLEGIA
TRIPLEGIA
QUADRIPLEGIA (TETRAPLEGIA)
TOTAL BODY INVOLVEMENT
MONOPLEGIA
MANIFESTRATION
SPASTIC DIPLEGIA 8- 10 MO.
SPASTIC HEMIPLEGIA 20-24 MO.
ATHETOID > 24 MO.
DEPEND ON MYELINATION
Factors affect walking ability
(diplegia)
Severity of lower ext. involvement
Seizure
Marked flaccidity
Persistent abnormal primative reflexes
Dislocated hip
Intelligence, mental retardation
Upper ext. involvement
Birth weight
BLECK’S WALKING PROGNOSIS
(after 12 mo.)
1. ASYMMETRIC TONIC NECK REFLEX
2. NECK RIGHTING REFLEX
3. MORO REFLEX
4. SYMMETRIC TONIC NECK REFLEX
5. EXTENSOR THRUST
6. PARACHUTE REACTION
7. FOOT- PLACEMENT REACTION
SCORE > 2 POOR
PROGNOSIS
PROGNOSIS
GOOD PROGNOSIS FOR WALKING
- HEAD BALANCE BEFORE 9 MO.
- INDEPENDENT SITTING BY 24 MO.
- CRAWLING BY 30 MO.
POOR PROGNOSIS
- LACK OF HEAD CONTROL BY 20 MO.
(Camposda paz)
PROGNOSIS
SITTING BEFORE 2 YR USUALLY WALK
INDEPENDENT
2-4 YR 50% WALK INDEPENDENTLY
> 4 YR RARELY STAND OR WALK WITHOUT SUPPORT
NEVER LEARN TO WALK BEFORE 8 YR UNLIKELY TO
WALK (Motor improve plateau 7 yr.)
(Beal )
PROGNOSIS
2 YR. WITH INDEPENDENT SITTING
- NOT A GOOD PREDICTOR FOR WALKING
ABILITY
INABILITY TO SIT AFTER 4 YR.
- PREDICTED NONAMBULATION
(Molnar and Gordon)
EVALUATION
HISTORY
OBSERVATION
EXAMINATION
GAIT ANALYSIS
OBSERVATION
POSTURE
GAIT
CROUCH
JUMP
PHYSICAL EXAMINATION
HIP FLEXION DEFORMITY
THOMAS TEST
Modified Thomas test
MODIFIED THOMAS TEST
STAHILI TEST
DUNCAN-ELY TEST
PHYSICAL EXAM.
ADDUCTION DEFROMITY
PHELPS TEST
KNEE EXAMINATION
KNEE FLEXION DEFORMITY
LACK OF FULL EXTENSION ON
INITIAL CONTACT,STANCE
AND INITIAL SWING PHASE
POPLITEAL ANGLE
SLRT
TEST FOR RECTUS TIGHTNESS
KNEE EXTENSION DEFORMITY
PHYSICAL EXAMINATION (SILVERSKIÖLD)
FOOT : EQUINUS DEFORMITY
MOST OFTEN IN HEMIPLEGIA
EQUINOVARUS DEFORMITY
VARUS DEFROMITY
TIBIALIS POSTERIOR HINDFOOT VARUS
OR
TIBIALIS ANTERIOR FOREFOOT SUPINATION,
HINDFOOT VARUS (SWING PHASE)
WEAK PERONEUS
PES VALGUS DEFORMITY
Peroneal hyperactivity
TREATMENTS
PRIORITY
COMMUNICATION
ADL
MOBILITY
WALKING
SURGICAL TREATMENT
SPASTIC TYPE
AGE 4-8 YEAR IS PROPER
YOUNGER
HIGH RECURRENCE
MATURE GAIT
~ 7 YEARS
SEQUENTIAL V/S ALL AT THE SAME
TIME
Surgical treatment
Hip flexion deformity
Thomas test 30O
Modified Thomas test 20O
Surgical treatment
Hip adduction deformity
Passive abduction < 30O
both in hip flexion & extension
HIP AT RISK
Quadriplegia, Nonambulator
Age 2-6 yr.
< 30O abduction in flex or ext.
> 20O flexion contracture
valgus and anteversion
Shallow acetabulum AI > 40
Abnormal migration index
FILM PELVIS EVERY 12 MO. FOR NONAMBULATOR
ACETABULAR INDEX
A
B
C
AB/AC= MIGRATION INDEX (MI)
> 1/3 = subluxation
SURGICAL TREATMENT ON THE
HIP
ADDUCTOR LONGUS TENOTOMY
ANT. HALF OF ADD. BREVIS
GRACILLIS
PSOAS TENOTOMY OR LENGTHENING
preserve iliacus
RECTUS FEMORIS LENGTHENING
PROXIMAL HAMSTRINGS RELEASE
MANAGEMENT OF HIP AT RISK
AGE < 4 YR. SOFT TISSUE RELEASE(45O Abd in
Ext,60O in Flex.)
AGE 4-8 YR.
MI 25-60%, ABDUCTION <30O ==>RELEASE
MI > 60%, NOT IMPROVE IN 1 YR.==> OR+
CAPSULORRAPHY+
BONY RECONSTRUCTION
AGE > 8 YR
MI
> 40% RELEASE & BONE RECONSTRUCTION
Flynn JM. AAOS 10(3): 2002
Hip subluxation
MI > 30 %
Soft tissue release for very young
MI > 50% open reduction + femoral
osteotomy
AI > 25O pelvic osteotomy
Management of hip dislocation
Observation
Open reduction + osteotomy + soft tissue
release
Resection arthroplasty
Arthrodesis
Total hip replacement
Neck shaft angle < 115O
Anteversion10-20O (30-45O passive IR)
SURGICAL TREATMENT ON THE
KNEE
SLRT < 60O, PA > 45O
MEDIAL HAMSTRINGS
RELEASE
LATERAL HAMSTRINGS
RELEASE
RECTUS FEMORIS RELEASE
RECTUS FEMORIS TRANSFER
HAMSTRING RELEASE
RECTUS FEMORIS TRANFER