gmfcs level iv cerebral palsy - aacpdm.org · gmfcs level iv cerebral palsy scott a. hoffinger,...
TRANSCRIPT
![Page 1: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/1.jpg)
GMFCS Level IV Cerebral Palsy
Scott A. Hoffinger, M.D.Clinical Professor Orthopaedic SurgeryStanford University School of Medicine
Vice Chief Operations, Stanford Children’s Orthopaedics
AACPDM 72nd Annual MeetingCerebral Palsy: Key Orthopaedic Issues
![Page 2: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/2.jpg)
GMFCS Levels:
• Descriptive
• Prognostic
• Allows for planning and outcomes analysis
![Page 3: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/3.jpg)
GMFCS in Orthopaedics:
• GMFCS I – won’t need surgery, visits typically start with “we certainly want to avoid surgery…”
• GMFCS IIa – may not need anything sophisticated (maybe soft tissue), possible SDRKids do very well
![Page 4: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/4.jpg)
GMFCS in Orthopaedics:
• GMFCS IIb – gets tighter, develops crouch, may have great benefit from SEMLS, possible SDR
• GMFCS III – critical population, can we preserve their gait? Careful selection and proper surgery possible may be dramatic
![Page 5: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/5.jpg)
Surgical Admonition:
• Contractures and deformity may NOT be the critical factors in any child wrt mobilty and gaitOther medical comorbidities
Weight
Behavioral issues
Social and environmental
![Page 6: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/6.jpg)
GMFCS in Orthopaedics:
• GMFCS V – try to keep hips in or resect*, fuse their spines
• Sit well, pain free, quality of life
*I hate this operation
![Page 7: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/7.jpg)
GMFCS Level IV:
• Where do they fit?
• Where does orthopaedics fit?
• Where do they end up as adults?
![Page 8: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/8.jpg)
Goal Setting in Orthopaedics:
• Often taken for granted because it is obviousFracture – straight and healed
Scoliosis – sorta straight but mobile
GMFCS I, II, and III – inclusion, activity, and (let’s face it) walking
![Page 9: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/9.jpg)
Everyone wants to walk:
• Even with III, we can speak of standing, sitting, but families want walking (and we oblige)
• GMFCS V – walking is off the table and this becomes clear
• Discussions about QOL
![Page 10: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/10.jpg)
GMFCS IV:
• Goal Setting is even more critical in this population
• Balance between dashing hopes / negativity and realism
• “…they said he’d never walk, I hate them…”
![Page 11: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/11.jpg)
What are GMFCS IV Goals?
![Page 12: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/12.jpg)
What are GMFCS IV Goals?
• By definition, teenager will not ambulate in community, yet how do we introduce this?
• When do we introduce this?
• How do we set the realistic, attainable goal, and what is that?
![Page 13: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/13.jpg)
GMFCS IV – Stand / Transfer:
• Walking 4 steps with a gait trainer is not functional when you are 25
• Adult adeli suits aren’t cool
![Page 14: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/14.jpg)
GMFCS IV = Standers:
• The difference between full lift and standing for xfers is huge
• The difference bt standing to pull up pants vs lifting off toilet
• This makes a significant impact on future care, QOL
• AND often attainable
![Page 15: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/15.jpg)
How to realize standing goal:
• Attainable = simple
• Principles of gait still applicable
• Requires:Plantigrade feet
PF / KE couple alignment
Minimal knee flexion contracture
Min – moderate hip flexion contrx
![Page 16: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/16.jpg)
Hips in standing:
• Stable hips are still important
• Don’t give up on hips especially if you can establish relationship to standing
• Nearly all same requirements for walking, a few exceptions…
![Page 17: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/17.jpg)
GL
Grant, age 12: Mom swears as his hips were watched
and got worse, his standing tolerance diminished
![Page 18: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/18.jpg)
Staged open reduction, femoral and Chiari osteotomies
Returned to standing full time, even taking steps in house
![Page 19: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/19.jpg)
Andrew, 13 years old
• Premature, diplegic
• Can assist with transfer
• Increasing pain with standing
![Page 20: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/20.jpg)
Over 2 years, advised:
• Too risky to relocateLikely to fail
Can get infected
Better to resect proximal femur
Daily narcotic use
![Page 21: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/21.jpg)
At 8 weeks off all narcotics
At 16 weeks back to standing for transfers
![Page 22: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/22.jpg)
Michael, slowing losing the ability to stand, let’s
watch it. 2 y later, too late to relocate
Age 9 Age 11
![Page 23: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/23.jpg)
Age 12, MRI ordered which confirmed hip could
not be put in due to “divot” and pain
![Page 24: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/24.jpg)
Age 13, open reduction, femoral and Chiari,
opposite femoral for LLD and symmetry
![Page 25: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/25.jpg)
Age 17, has been standing for transfers, climbs up
stairs. He weighs 140, Mom weighs 95 lbs
![Page 26: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/26.jpg)
DFEO for ambulatory
children holds up well
with very low
recurrence (in properly
selected children)
What about knee contractures:
![Page 27: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/27.jpg)
Not so certain in this population:
Seems to have far greater recurrence when done for
standing as opposed to full time ambulation
![Page 28: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/28.jpg)
A good population for anterior tether:
Timing is still a bit fuzzy, but around age 10 works well
![Page 29: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/29.jpg)
Carson: age 11, was a III – IV and unclear where he
would end up, plates are annoying
![Page 30: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/30.jpg)
2 ½ years later, standing improved, takes some steps, has
NOT lost flexion, so we are keeping these in place
![Page 31: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/31.jpg)
Been using screws placed lateral to patellar articulation.
Recovery is FAR easier, but return of growth not established
![Page 32: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/32.jpg)
Restoration of
plantarflexion / knee
extension moment
remains important
for success.
These feet will never
help knees extend
Finally, the feet:
![Page 33: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/33.jpg)
Osteotomy needs to correct alignment and
hold up over time – older kids do better
Dealer’s choice as to procedure:
![Page 34: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/34.jpg)
Concern about longer term arthritic
changes likely not applicable for standing
Subtalar or triple valid option:
![Page 35: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/35.jpg)
Conclusions GMFCS IV:
• Set attainable goals early, and reiterate this to the team
• Standing probably matters more and is more attainable in IV’s
• Overall health status can determine success, not everyone is surgical candidate
![Page 36: GMFCS Level IV Cerebral Palsy - aacpdm.org · GMFCS Level IV Cerebral Palsy Scott A. Hoffinger, M.D. Clinical Professor Orthopaedic Surgery Stanford University School of Medicine](https://reader031.vdocument.in/reader031/viewer/2022020416/5cfad17988c993146c8cf383/html5/thumbnails/36.jpg)
Conclusions GMFCS IV:
• We have all the surgical tools to have substantial and significant impact
• Still requires good decision making, planning, and execution