the role of orthopedic surgery in the management of ... role of orthopedic surgery in the management...
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The Role of Orthopedic Surgery in the Management of Children with Cerebral Palsy
Hank Chambers, MDSan Diego Children’s Hospital
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Indications for Orthopedic Surgery
• Fixed contracture affecting function
• Joint dislocations• Rotational Abnormalities• Shoe wear problems• Pain• Perineal hygiene problems
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Planning for surgery
• Nutritional assessment• Stability of neurologic state• Do you expect the patient
to improve over time?
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Radiographic Assessment
• Plain Radiographs of joints – Anterior-posterior– Lateral
• Computed Tomography• Three dimensional Computed
Tomography
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Gait Analysis• To assess the walking ability of the
child and to determine the cause of the walking abnormality
• Observational• Three dimensional Motion Analysis
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Timing of the Surgery
• Stroke: after at least 6 months• Closed Head Injury: at least 9 months• Spinal Cord Injury: at least 12 months• Anoxia: at least 12 months• Cerebral Palsy: delay until 6-8 years
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Timing in Cerebral Palsy
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Principles of Orthopedic Surgery
• Single event, multilevel surgery• Delay surgery as long as possible (> 6
years) • Use spasticity management as adjunct
to surgery
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Avoid the Birthday Cake and Diving Syndrome• Series of operations done one year
apart so that child is either in the hospital or in recovery at all times
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To improve muscular problems
• Tendon Lengthening• Intramuscular Lengthening• Muscle release• Tendon Transfer• Neurectomy
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Effect of Lengthening on Muscle
• May reset the Golgi tendon complex
• Affects the muscle spindle• Resets the feedback for the
stretch reflex
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Tendon Lengthening
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Fascial Lengthening
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Muscle Release
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Tendon Transfer
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Neurectomy
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To improve static problems• Reduce subluxated or
dislocated joints• Correction of bony
abnormalities and rotational problems
• Fuse joints to provide stability• Excision of heterotopic bone
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Reduce subluxated or dislocated joints
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Correct Rotational Abnormalities
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Fuse Joints for Stability
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Orthopedic Surgical Interventions: Spine
• Intervention to correct– Scoliosis– Spondylolisthesis– Hyperkyphosis– Hyperlordosis
DeLucaDeLuca PA. PA. Pediatr Clin N AmPediatr Clin N Am 1996;43:11351996;43:1135--50.50.
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Excise Heterotopic Bone in Head Injured Patients
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Postoperative Care• Postoperative Pain Management with
– Epidural blocks– Caudal blocks– Local Nerve blocks– Local Anesthetic at the incision site
• Manage Spasticity with Oral Medication such as diazepam
• Short term or no casting postoperatively
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Rehabilitation• Most important part of orthopedic
surgery• Usually provide a 6-8 week period of
intensive therapy (2-3 times/week)• Work on strengthening as soon as
possible• Immobilize as little as possible
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Role of Orthotics and Braces
• Rarely use full leg braces in ambulatory patients
• Role of Serial Casting• Can use hip abduction brace to maintain
hips in acetabulum• Use articulated or hinged Ankle-foot
Orthoses (AFO) in ambulatory patients• Orthotics rarely work in children with
valgus flat feet.
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So What does Orthopedic Surgery have to Offer?
• Lengthen tendons• Transfer tendons• Relocate joints• Rotate bones• Fuse joints• Cut nerves