cerebral palsy treatment
DESCRIPTION
TRANSCRIPT
![Page 1: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/1.jpg)
CEREBRAL PALSY TREATMENT
By Dr.Tejaswi DussaPg In Ms OrthoGmc , Sec-bad
![Page 2: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/2.jpg)
TREATMENT PRINCIPLES
• Though CNS insult is non progressive- deformities caused by abnormal muscle forces and cotractures are progressive
• Treatment is not aimed at primary cause but to correct secondary deformities
• Deformities worse during time of growth it is better to delay few definitive surgeries to decrease the risk of recurrence
• Combined approaches (operative, non operative) are benificial
![Page 3: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/3.jpg)
OBJECTIVES
• Stabilization of joints for wieght bearing• Prevent deformity• Overcome deformity• Establish muscle balance
![Page 4: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/4.jpg)
NON OPERATIVE TREATMENT
• Commonly used as primary treatment or in conjuction with surgery
MedicationSplintingbracingPhysical therapy
![Page 5: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/5.jpg)
MEDICAL MANAGEMENT
• Common agents - diazepam - baclofen - dantrolene - botulinum toxinOral agents:• Diazepam increases inhibitory neurotransmitter
activity (GABA)• Baclofen inhibit abnormal monosynaptic extensor
activity and poly synaptic flexor activity and decrease substance P levels
![Page 6: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/6.jpg)
• -oral baclofen• -intrathecal baclofen injection
![Page 7: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/7.jpg)
• Intramuscular–Phenol–BTX
– Intra muscular botulinum toxin for 2-6 months– Safe maximal dose 36-50 U/kg
![Page 8: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/8.jpg)
Botox Indications contraindication
• Pre op Evaluation • Improve Muscle
balance for ROM• Improve function
(ADLs).• Reduce spasticity
(discomfort)• Post op analgesia
• Fixed contractures• Serious weakness• Aminoglycosides• Previous failure
![Page 9: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/9.jpg)
ORTHROSIS
Choice of orthrosis is based on• Assessement of range of motion• Foot alignment• Voluntary contol of movement in lower
limbs• Functional level of child
![Page 10: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/10.jpg)
• Support the jonts• assists the range of movements• Correct deformities• During physical therapy
![Page 11: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/11.jpg)
![Page 12: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/12.jpg)
Ankle foot orthosis
![Page 13: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/13.jpg)
Floor reaction AFO
• Uses floor reaction force through toe aspect of foot plate to prevent forward tibial progression & subsequent knee collapse
• May be articulated
![Page 14: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/14.jpg)
Knee brace
![Page 15: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/15.jpg)
Ankle-foot-knee orthrosis
![Page 16: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/16.jpg)
![Page 17: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/17.jpg)
![Page 18: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/18.jpg)
Abduction spint
![Page 19: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/19.jpg)
SWASH orthosis
![Page 20: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/20.jpg)
![Page 21: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/21.jpg)
GAIT TRAINING
• Adequate base of support
• Appropriate foot clearance
• Adequate step length• Conservation of
energy
![Page 22: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/22.jpg)
Gait trainer
![Page 23: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/23.jpg)
Assisted Gait Trainer
![Page 24: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/24.jpg)
Walking aids
• Axillary crutches• Elbow crutches• Walking sticks
![Page 25: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/25.jpg)
• In management of CP patient
how to do a procedure is not a big deal but
what procedure to do is most important
• Without prior gait analysis the chance of falty diagnosis and choice of treatment in experience hands is almost 50%
• Choice treatment as per clinical diagnosis will be definitely altered after gait analysis
![Page 26: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/26.jpg)
GAIT ANALYSIS
• To diagnose mechanisms responcible for gait disorders
• To assess the degree of disability• To evaluate the improvement resulting from
treatment
![Page 27: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/27.jpg)
APPROACHES
• Obeservational gait analysis• Gait parameters• Kinematic data• Force plate data• Kinesiological data• energetics
![Page 28: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/28.jpg)
MANNERISMS
• No abnormalities• They are only individual characteristics
![Page 29: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/29.jpg)
OBSERVATIONAL GAIT ANALYSIS
![Page 30: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/30.jpg)
OBSERVATIONAL GAIT ANALYSIS
![Page 31: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/31.jpg)
GAIT PARAMETERS
• Gait parameters - cadence (90 steps/min)- step length(0.7-0.9 m)
- walking velocity(60-90 m/min) - single limb support (0.5-2 sec)
![Page 32: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/32.jpg)
Kinesiological analysis
• Combined motion ,forces, muscle function
![Page 33: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/33.jpg)
Kinematic analysis
![Page 34: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/34.jpg)
Force plate analysis
ground reaction force
![Page 35: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/35.jpg)
![Page 36: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/36.jpg)
SURGICAL MANAGEMENT
OF HIP
![Page 37: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/37.jpg)
Aims of operative management
• Evaluate muscle tone and determine type.• Evaluate degree of deformity / contracture at each
joint.• Assess linear, angular and torsional deformities of
spine, long bones, hands and feet.• Appraise balance, equilibrium and standing / walking
posture. • Correct static or dynamic deformities• balance muscle power across the joint• reduce spasticity• Stabilize uncontrollable joints
![Page 38: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/38.jpg)
with
• Early regular stretching of tightened structure• Reeducation and exercising weak antagonists• Proper bracing• Traning of balance and posture• Locomotion and relaxation• Speech therapy“ MOST PATIENTS NEVER REQUIRE SURGERY”And achieve good balance and independent gait
![Page 39: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/39.jpg)
OPERATIVE MENAGEMENT
• Indications • contracture or deformities causing pain Decrease function Interfere with ADL
![Page 40: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/40.jpg)
PREREQUISITES FOR EFFECTIVE SURGERY
• spastic• hemiplegics / diplegics : good results quadriplegics : minimal improvement• Age : 3- 12 years• IQ : good• Good upper limb function : for walking• Underlying muscle power should be good
surgery hardly changes status in walkers/nonwalker, but improves gait
![Page 41: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/41.jpg)
PROCEDURE
• Neurosurgical procedures• Tendon release• Muscle tendon lengthening• Capsulotomies• Osteotomies• Resection and replacement procedures
![Page 42: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/42.jpg)
NEUROSURGICAL • SELECTIVE DORSAL ROOT RHIZOTOMY• 30 – 50 % of abnormal dorsal rootlets L2 - S1• Pt selection:child 3-8 yrs with spastic diplegia voluntory motor and thrunk control pure spastic and no fixed contracture• With physical therapy continued improvement can be
expected for 6-12 months• Not recommonded in -spastic quadriplegia -spastic hemiplegia • Complication: hip subluxation/dislocation lumbar hyperlardosis spondylolysis/listhesis
![Page 43: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/43.jpg)
HIP IN CEREBRAL PALSY
• All hips should be considered abnormal unless proved otherwise
• Deformities ranges from mild painless subluxation to complete dislocation
• Pain and joint distruction• Impaired mobility
![Page 44: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/44.jpg)
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
![Page 45: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/45.jpg)
A B C
AB/AC= MIGRATION INDEX (MI)
ACETABULAR INDEX
33%subluxation100%dislocation
![Page 46: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/46.jpg)
DEFORMITIES• DEFORMITIES OF HIP:• Flexion deformities• adduction• Subluxation and dislocation
• SECODARY DEFORMITIES:• Knee Flexion • Version deformities of tibia• Equinus foot• Pelvic tilt• Scoliosis• lordosis
![Page 47: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/47.jpg)
Causes of hip deformities
• Causes:• Muscle imbalance• Retained primitive reflexes• Abnormal positioning• Pelvic obliquity
• Structural changes• Acetabular dysplasia
• Excessive femoral anteversion• Increased neck shaft angle
• osteopenia
![Page 48: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/48.jpg)
• Pseudoadduction deformity
Flexion internal rotation of hip
Incresed femoral anteversion
External tibial torsion Planovalgus feetPt sit in the ‘W’ position
![Page 49: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/49.jpg)
![Page 50: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/50.jpg)
![Page 51: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/51.jpg)
![Page 52: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/52.jpg)
Hip flexion deformity
![Page 53: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/53.jpg)
Indication for surgery
• Hip flexion deformity never decrease by physiotherapy – orthoses – sleeping prone …
• Hip flexion deformity > 20 needs surgery
![Page 54: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/54.jpg)
Hip flexion contracture hip , knee & ankle contractures
single stage 15-30 deg flexion >30 deg flexion multi level correction
ilioPsoas lengthening more release of -rectus femoris
-sartorius -TFL -anterior fibers of Gl.minimus Gl.medius
![Page 55: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/55.jpg)
• Iliopsoas recession is most commonly used than complete tenotomy to avoid excessive
flexion weakness
![Page 56: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/56.jpg)
![Page 57: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/57.jpg)
• Lengthening (z plasty) : best / easy satisfactory in ambulating patients. no risk of too much weakening of flexion power
keatsILIOPSOAS RELEASE• Better in non ambulatory
patients• Release at insertion of
iliopsoas • Causes risk of excessive
weakness of hip flexon• Often done with adductor
release and varus derotational osteotomy
ILIOPSOAS RECESSION
• M.c used• Preferred in ambulatory
patients• good for subluxated hip• Adviced when hip
internally rotated during walking
![Page 58: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/58.jpg)
• After treatment• Co-operative pt immediate physiotherapy
started with hip extension and external rotation
• Non co-operative ptpt are placed prone at bed
![Page 59: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/59.jpg)
What not to do !• Yount’s fasciotomy of Tensor F. Lata – not
enough• Souter’s muscle sliding of Sartorius, Rectus
Femoris, and Tensor Fascia Lata – 66% recurrence
• Proximal Rectus Femoris tenotomy• Myotomy of ant. Fibers of Gluteus Medius very important pelvic stabilizer in stance
phase
![Page 60: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/60.jpg)
ADDUCTION DEFORMITY
![Page 61: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/61.jpg)
ADDUCTION DEFORMITY
• AGE < 4 YR <45o abduction in ext, 60o in flex soft tissue
release
• AGE 4-8 YR. MI 25%-60%,
abduction <30o soft tissue release
MI > 60%, not improve in 1 yr soft tissue release+ capsulorraphy+ bony reconstruction
• AGE > 8 YR MI > 40% soft tissue release &
bone reconstruction
![Page 62: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/62.jpg)
• Mild contracture severe contractures Early hip subluxation
• Adductor tenotomy more release of -gracilis -anterior half of
adductor bevis
• Leave adductor brevis ( the major hip stabilizer )• No anterior branch obturator neurectomy (Nerve to adductor brevis)• Release brevis if can not abduct 45*
![Page 63: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/63.jpg)
Banks and green procedure
![Page 64: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/64.jpg)
After treatment:Abduction bar for 1month
![Page 65: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/65.jpg)
HIP SUBLUXATION
• MI > 30 %Soft tissue release for very young Flexion adduction deformities
• MI > 50% open reduction + femoral osteotomy Correction of femoral valgus and anteversion
• AI > 25O pelvic osteotomy (Correction of acetabular deformities)
![Page 66: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/66.jpg)
• Femoral varus and derotational(external rotation) osteotomy
• Acetabular osteotomies:• Salter osteotomyredirection of the
acetabulum anterioly and laterally• Postero-superior deficiencyshelfs
osteotomy
![Page 67: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/67.jpg)
Neck shaft angle < 115O
Anteversion10-20O (30-45O passive IR)
![Page 68: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/68.jpg)
HIP DISLOCATION
• MI=100%Types:• Posterior dislocation (m.c)• Anterior dislocationSeen in -spastic diplegics -spastic quadriplegics
• Significant acetabular changes present
![Page 69: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/69.jpg)
Spastic Diplegia Spastic quadriplegia
![Page 70: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/70.jpg)
hip dislocation : if detected early: surgery if detected late : no pain – leave
pain – proximal resection
![Page 71: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/71.jpg)
• Criteria for open reduction of a dislocated hip:
• Moderate intellectual• Should have atleast sitting potential• Pelvic obliquity should be minimaldislocation
ideally unilateral• No longer duration of dislocation
![Page 72: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/72.jpg)
TRETMENT OPTIONS IN HIP DISLOCATION
• Observation• Relocation procedure on femur and acetabulum• Proximal femoral resection• Hip arthrodesis proposed for • Total hip arthroplasty painful unreducible dislocated hip
![Page 73: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/73.jpg)
Combined one stage correction of spastic dislocated hip
1. Soft tissue release2. Open reduction3. femoral osteotomy4. Pericapsular pelvic osteotomy
![Page 74: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/74.jpg)
Varus derotational shortening femoral osteotomy
![Page 75: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/75.jpg)
Pericapsular acetabuloplasty
![Page 76: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/76.jpg)
![Page 77: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/77.jpg)
![Page 78: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/78.jpg)
PROXIMAL FEMORAL RESECTION
![Page 79: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/79.jpg)
NON AMBULATORY CP HIP DISLOCATION
• Resection
• Valgus Osteotomy
• Arthrodesis
• Arthroplasty
• Femoral & Pelvic osteotomy
![Page 80: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/80.jpg)
Proximal Femoral Resection
Leet et al JPO 2005
![Page 81: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/81.jpg)
Valgus Osteotomy
![Page 82: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/82.jpg)
Arthroplasty
Miller et al JPO 1999
![Page 83: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/83.jpg)
Arthrodesis
40* flexion,15*abduction and neutral rtation
![Page 84: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/84.jpg)
Femoral & Pelvic Osteotomy
![Page 85: Cerebral palsy treatment](https://reader033.vdocument.in/reader033/viewer/2022061117/546635b3af795969338b5128/html5/thumbnails/85.jpg)
Thank you