CEREBRAL PALSY

RECONSTRUCTIVE LIMB SURGERY

Goals, Role and Timing

ANISUDDIN BHATTI
at

2nd National Workshop 19th March 2011

Decision Making Process

RECONSTRUCTIVE LIMB SURGERY

CEREBRAL PALSY
Objectives Background Why I Choose this topic Role What & Why? Timing When & When Not to Do. Preparations How Rehabilitation & Few other aspects

CP RECONSTRUCTIVE SURGERY
Orthopaedic surgery have the permanent and important role in management of CP child. Factors: Decision making process for surgery:
1. Age Grouping. 2. Clinical pattern. 3. Prognosis of Walking: (Ability to walk independently) . 4. Structural changes. 5. Cosmetic improvement in gait.

CP RECONSTRUCTIVE SURGERY
Decision Making Process

1. AGE GROUPING for surgical corrections:

i. Pre-school age ii. School age iii. Adolescent and adults

CP RECONSTRUCTIVE SURGERY
Decision Making Process

2. CLINICAL PATTERN: Hemiplegia / Monoplegia Diplegia / Paraplegia Total Body Involvement Athetoid Ataxic Spastic: most common & Maneable Dynamic Static

3.

PROGNOSIS OF WALKING

CP RECONSTRUCTIVE SURGERY
Decision Making Process
3. PROGNOSIS OF WALKING- Sitting: Ability to sit is the major indicator for the ability to walk independently.
Under age 2 years, the ability to sit independently is not a good predictor of walking But After age 4 years, Inability to sit do predict nonambulation
(Molnar-Gordon)

CP RECONSTRUCTIVE SURGERY
Decision Making Process

3. PROGNOSIS OF WALKING- Other

Indicators:

All Hemiplegics walks between 18-21 months. Most Spastic Diplegics walks by 48 months. Quadriplegic children (with TBI) have poorest prognosis.
Ambulatory ability reaches a plateau by the age 7 years
(Accuracy for walking prediction 94.5%)

CP RECONSTRUCTIVE SURGERY
Decision Making Process
3. PROGNOSIS OF WALKING

Criteria to Qualify as a Walker:

Assessment to Qualify as walker should be made after the age 7 years

Walker: when child could walk a minimum of 15 meters without falling

Functional Walker: when a child could walk only with crutches. Non-Walker: when child could walk with aid of mobility device or only in parallel bars

CP RECONSTRUCTIVE SURGERY
Decision Making Process

3. PROGNOSIS OF WALKING: Why to Predict ? Ability to make a reasonably accurate PREDICTION about walking allows the Orthopaedist to DELAY SURGERY, merely to force the child to walk and reduces role of surgery in non-ambulatory patient & preventing serious structural changes in the hips.

CP RECONSTRUCTIVE SURGERY
Decision Making Process 3. PROGNOSIS OF WALKING: Prognostic testing for walking also benefits the various THERAPY & PROGRAMMES because it permits JUDGMENT to be made on efficiency of various treatment programmes that use ability to walk a criteria of success. Good Results can be obtained in 75-95% Patients

CP RECONSTRUCTIVE SURGERY
3. PROGNOSTIC INDICATORS: Beals Motor Quotient

Motor performance of spastic Diplegic children.

From birth to about 3 years , the functions that were thought to be absent before this age may develop spontaneously with neuronal maturation. Motor gains reaches plateau or cease between 6-7 years. No change in motor performance, after age 7 years.

Motor performance of spastic Diplegic children

CP RECONSTRUCTIVE SURGERY
3.PROGNOSTIC INDICATORS: PREDICTION OF WALKING
Beals Severity Index & Goal to Achieve free Ambulation:

Severity Index (SI) shows Motor Age in Months at 3 yrs. The prediction for walking can be determined on SI as follows: SI Ability to walk Surgery
(Motor Age in months) Goal to achieve free ambulation

12-18 10-11 9 9-0

Free walking by age 7 yrs Lowest score consistent with free walking is reasonably good
Crutch walking

Surgery only to improve walking. Surgery may be performed to reach Goal.

No Surgery.

No walking

No surgery.

CP RECONSTRUCTIVE SURGERY
Decision Making Process

4. STRUCTURAL CHANGES:

CP RECONSTRUCTIVE SURGERY
Decision Making Process

4. STRUCTURAL CHANGES: On long term followup progression of structural changes in joint are well evident despite assiduous therapy and bracing. That may be a: 1. Painful degenerative arthritis as a result of hip subluxation, that too jeopardize Spastic walking after 18 years. 2. A dislocated hip that become painful at late adolescent.

CP RECONSTRUCTIVE SURGERY
Decision Making Process

4. STRUCTURAL CHANGES: Orthopaedic surgery in late adolescent is more difficult, has more complication and causes on increased incidence of post operative psychological problems. Therefore: Orthopaedic surgery to prevent and correct structural change ought to be performed before age of 15 (13) years.

CP RECONSTRUCTIVE SURGERY
Decision Making Process

1. AGE GROUPING for surgical corrections:

i. Pre-school age (< 5 years) ii. School age (> 5 12 years) iii. Adolescent and adults (> 13 Years & Above)

C P IN PRESCHOOL CHILD

PRE SCHOOL CHILD

Delay the Surgery, till ?

Better to defer surgery for functional and cosmetic improvement of gait until the child has learned to walk and Walked independently for a year, at least

PRE SCHOOL CHILD

Because: A. If a child has a good prognosis of walking surgery will not hasten the development of ambulation. Infact: Surgery particularly on feet, may even delay the walking (Bleck)

Delay the Surgery, till ?

Sometimes: Surgery is given a credit, that it may allow the child to walk. It may be a dramatic therapeutic triumphs'. However: That happen only when, The surgery timing coincide with the development of onset of independent walking. that may not always be true

PRE-SCHOOL CHILD
Delay the Surgery, till ?

B. When there is no structural changes (e.g. hip subluxation or Gastro-Solius and knee contracture) there is no harm to delay surgery until child can walk Exception to this Rule: This rule may not applied in pre-school child when prevention of sub-luxation and dislocation of hip is necessary. Therefore: In all children with spastic muscle, radiograph of hip should be made in infancy and every 6-8 months. If Subluxation is noticed spastic muscle release should be done.

PRE-SCHOOL CHILD:
TYPE OF SURGERY
Loco-motor prognosis determines the type of surgery needed: I. Poor prognosis of walking & child having subluxation of hips: Myatomy of adductor Longus & Gracilis Neuroctomy of anterior branch of obturetor nerve Iliopsoas tenotomy.

PRE-SCHOOL CHILD:
TYPE OF SURGERY
Loco-motor prognosis determines the type of surgery needed: II. Good prognosis for walking: Dont risk for the permanent weakness of hip flexor by Iliopsoas tenotomy. lengthening or recession of Iliopsoas muscle is preferable.

Never release ankle & knee, before the child has walked independently.

C P IN SCHOOL AGE CHILD

SCHOOL AGE CHILD

TIMING OF SURGERY

A) The optimum time for lower limb surgery in ambulatory child is between ages of 5-7 years, as at this age the gait pattern can be analyzed easily. B) Try to finish most treatment programmes by the age 7-8 years (Bleck)

B) Surgery should not be staged over period of a years, perform one stage surgery under single anesthesia.

SCHOOL AGE CHILD

TIMING OF SURGERY

Repeated examination, careful analysis of the gait problem and recognition of potential skeletal changes lead to better judgment to correct or prevent structural changes reasonably early i.e before 15 (13) years.
(Molnar-Gordon)

Gait Laboratory Plays important role in accurate Judgment

Gait Laboratory:
Pedogram:
Cavovarus & Planovalgus

EMG:
Weak Muscles

Indicating spastic, normal &

Visit to Gait Laboratory

NED Biotechnology Campus 18th March 2011

C P IN ADOLESCENT & ADDULT

ADOLESCENT & ADDULT

Fixed contracture often present. Functional improvement is not as satisfying. In late adolescent (>15 years) correction of deformities often cause pain and discomfort in hip, knee ankle and foot. In adult; mostly surgery for painful degenerative arthritis secondary to subluxation and dislocation is required.

Cerebral Palsy

Clinical Pattern

Specific Problems
DO & DONT DO

UPPER LIMB

CP RECONSTRUCTIVE SURGERY
Upper Limbs
PROGNOSIS FOR UPPER LIMB FUNCTIONS is poor when there is failure to develop: Limb Dominance. Lateralization. Ability to cross mid line.
Function will always be compromised, when Stereognostic sensation in hand is deficient. Child will use his eyes (Visual feed back) to control his hands. Intelligence always paralleled the upper limb severity index.

CP RECONSTRUCTIVE SURGERY
Upper Limbs
Beals Severity Index for upper limbs, with motor age in months at 3 years
SEVERITY INDEX 0-6 7-11 12-17 DISABILITY Profound Disability Moderate Disability Mild disability

SPASTIC HEMIPLEGIA: Upper limb

The surgery should be deferred until motor pattern is established and child is old enough to cooperate. Generally agreed age is 4 years. Exception to this general rule: severe pronater spasticity, leading to posterior subluxation of head of the radius. Several different surgical procedure can be done at one time. Thumb and wrist deformities should be corrected simultaneously.

HEMIPLEGIA

SPASTIC HEMIPLEGIA: Lower Limb

a. There is no evidence that manual stretching exercises, plaster casts or orthosis have ever effected a release of the contactures. b. All the procedures are designed to reduce the stretch relax and to lengthen the muscle. All procedures weaken the muscles Too much weakness causes over dorsiflexion. A calceneus deformity is functionally worse then the equinous deformity.
Results of Therapy in a patient with spastic Hemiplegia are often better then in those in diplegia because there is a normal apposite limb.

SPASTIC HEMIPLEGIA Equinous Deformity:

Test: If foot is capable of dorsi-flexion to neutral position when measured with planter surface of heel and foot in varus position (to lock the mid tarsal joint) surgery is not indicated in most patient.

SPASTIC HEMIPLEGIA Equinous Deformity:

Post operative functional results of Achilles tendon lengthening can be ascertained preoperatively by:
If patient can voluntarily dorsiflex foot with the knee fully extended, the post operative gait may be almost normal. If However, foot can be dorsiflex only when the knee is flexed at 90 degrees and when hip flexion is resisted, then the postoperative gait will be improved, but a step page gait (hip and knee flexed) will persist so that toe can clear the foot during swing phase.

Surgery for Spastic GastrocSolius

SPASTIC HEMIPLEGIA Knee flexion deformity

Hamstring lengthening is indicated when FFC is >15o during stance phase of gait. Patient who tolerate </=15o FFC of knee, are those who have good hip extension that locks the hips and brings trunk forward anterior to knee, in addition to that ankle planter flexors serves to over come flexed knee at mid-stance and beyond.

SPASTIC HEMIPLEGIA HIP, KNEE, ANKLE CONTRACTURE

TEST: If patient could stand erect with a A/K cylinder plaster only: - Hamstring are lengthened If he could stand erect with a short leg B/K walking plaster only: - Achilles tendon needs lengthening. If there is forward trunk lean with either cast: - Iliopsoas recession is recommended.

SPASTIC HEMIPLEGIA HIP, KNEE, ANKLE CONTRACTURE

If there is structural deformity at hip & ankle these deformities should be corrected at the same time as knee flexion deformity. If Hamstring lengthening is done and FFC hip persist over 15o, unacceptable lumber lordosis develop and trunk leans forward.

SPASTIC HEMIPLEGIA Hip flexion Contracture

Iliopsoas recession and derotation femoral subtrochanteric osteotomy corrects gait of practically all such hemiplegic children to almost normal in function and appearance. Most common PITFALL of femoral derotation osteotomy in Hemiplegic child is failure to recognize and treat simultaneously the concomitant excessive external tibial fibular torsion (>30o).
If Untreated tibial torsional deformity of leg becomes glaringly evident after correction of femoral torsion. To prevent this unhappy result derotation osteotomy of proximal tibia and fibular must be done.

DIPLEGIA

Both are DIPLEGIA but with Different Pattern

DIPLEGIA & PARAPLEGIA

Surgical procedure, its timing & indications are nearly similar as in Hemiplegia, the only difference is, the surgery on both side has to be performed simultaneously under same anaesthesia.

Correction of Structural Deformities in Diplegics

TOTAL BODY INVOLVEMENT

TOTAL BODY INVOLVEMENT Problems & Structural Changes

Most common orthopaedic problem in these patient are contractures and dislocations of hip, scoliosis, knee flexion contractures and equinous deformity.
Structural changes are particularly distressing in athetoids. Walking is usually not possible

TOTAL BODY INVOLVEMENT Problems & Structural Changes

If skeletal changes in hip and spine persist without correction, degenerative changes occur in the joint, causing added pain and disability.

T B I: Goal Setting
The goal setting and problem solving for the individual patient with TBI, should be done according to the priorities established by adults with CP: 1. Communication 2. Activities of daily living 3. Mobility 4. Walking

T B I: STRUCTURAL DEFORMITIES: Spine

Scoliosis: 25 38 % - Spinal curve of 42-50o may not respond to a orthosis if it is more than 50o surgical correction and fusion is indicated. - TBI Scoliotic spines are often rigid, one stage surgical correction may fails.

T B I: STRUCTURAL DEFORMITIES: Hip

Adduction contracture interfere with perineal hygiene, Sitting balance due to pelvic obliquity. In crossed leg deformity, intrapelvic obturetor neuroctomy is indicated with adductor myotomy. But exclude presence of tension athetosis other wise it will lead to excessive abduction. FFC Hip need not be relieved in non ambulatory patient ; however if subluxation of hip -- Iliopsoas tenotomy is needed

T B I: STRUCTURAL DEFORMITIES: Hip Dislocation

Hip dislocation occur almost exclusively in non- ambulatory total body involvement Prevention of dislocation by early surgical treatment appears to be a good policy.
Orthotics and physiotherapy have not demonstrated efficacy to prevent dislocation.

T B I: SURGICAL TREATMENT OF DISLOCATION

Whether all dislocation need surgery ?? as children aged 7-16 years have no pain with dislocated hip. Often Yes: because relocation in later years, become painful (47%) and modified Girdlestone had a poor results.

T B I: SURGICAL TREATMENT OF DISLOCATION

Relocation of dislocated hip in children and adolescent is indicated: 1. To prevent a painful hip in adult life that may compromise patients limited mobility 2. To prevent and correct sever pelvic obliquity, that interfere with sitting balance. 3. To prevent and correct severe adduction of the femur, that makes perineal hygiene difficult 4. To prevent painful bursal formation over greater trocharter on the dislocated side and over the Ischeal tuberosity when pelvic obliquity become fixed

T B I: SURGICAL TREATMENT OF DISLOCATION

Surgery is limited solely to:
- Adductor release + obturetor neurectomy (optional) - Iliopsoas tenotomy (essential preventive surgery) - Iliopsoas tenotomy done before 7-8 years age has significantly good results. After this age skeletal reconstruction is also required.

Acetabuloplasty has not been consistently successful.

T.B.I: KNEE FLEXION DEFORMITY

Knee FD need be corrected only if such knee FD interfere with assistive transfer from the wheel chair or positioning in bed become uncomfortable F.F.C more 15-20 should not be allowed to develop before that hamstring lengthening should be done. In adult combined supracondylar osteotomy & hamstring lengthening is the safe procedure.

TBI: Equinous Deformity

Since Walking is usually not possible in TBI, foot deformity correction is often not required. Your Opinion may differ in this case.

Rehabilitation & Other factors

Rehabilitation
Physical Mental Social Psychological Occupational

Rehabilitation

Pre-Operative PREPRATION OF CHILD & PARENTS

The child and parent must feel secure with the surgeon. Child and parent familiarity with physical therapies for the period of 3-4 months before surgery is mandatory (Ideal), to gain full cooperation of child in postoperative rehabilitation if child is inordinately fearful or anxious,

Pre-Operative PREPRATION OF CHILD & PARENTS

Delay the surgery till he / she: a) Gains confidence able to accept reality of hospitalization b) Recognize the need to take medications for post-op discomfort. c) Under stand the need of continuous post of rehab programme for a estimated period of time.

Pre-Operative PREPRATION OF CHILD & PARENTS

EXPECTATIONS FROM SURGEON & SURGERY

The parent and child must be made understand that: a) Post-op period may be painful but will be made comfortable with medication. b) 1st two post op days shall be more difficult c) Multiple incision will be made, preferably absorbable sutures will be used, to avoid stitch removal pain. d) POP cast, its extent and change. e) Length of cost immobilization and after such time child may be allowed walk in plaster.

EXPECTATIONS FROM SURGEON & HOSPITAL

Child and his parents should be told what to expect of Hospital organization, Hospital services and OT room. Admit 2-3 days before surgery to
Get optimum psychological benefit Enhance a smooth recovery Able to integrate many radical changes in his life An atmosphere need to be created, where the child feels like having a best friend in the hospital.

Post operative Rehabilitation

Include: POP cost for a limited time Early mobilization Children do not require an unduly prolonged period of post operative rehabilitation. Usually a maximum of 6 months post operative physical therapy under supervision

HOSTILE PARENTS
Parents (sometimes older children) are displacing their resentment that this disaster has occurred to them. Their hostility is often directed against one who confronts them with the painful realities, they would rather not face. Surgeon must have patience with seemingly hostile parents.

SPASTICITY CONTROL Rhizotomy Drug Therapy

Muscle Relaxants

Spasticity Control
When reduced patients may : - perform integrated muscle movement - develop muscle strength - function at a higher level Approaches : Selective dorsal rhizotomy Intrathecal baclofen Botulinum-A toxin

Selective Dorsal Rhizotomy

30 50 % of abnormal dorsal rootlets L2 - S1 Followed by intensive physiotherapy Results encouraging May cause hyperlordosis / hip subluxation Best for : spastic diplegia, 4-8 yrs, no previous
surgery, no contractures, no extra pyramidal signs

? Not enough alone Orthopedic procedures obtain similar results

Baclofen
Oral : mixed reports/ side effects/ not selective GABA agonist inhibits release of excitatory neurotransmitter at level of spinal cord Continuous intrathecal implantable pump Good results in releasing spasticity, and improving function Complications of pump and catheter Needs specialized centers

Botulinum-A Toxin
Acts at myo-neural junctions inhibits exocytosis of Acetylcholine Inject selected muscles at multiple sites Spasticity reduction may last up to 6 months Reversible , painless , minimal Role : side effects - Facilitates physiotherapy and mobilization Most patients still require - Delays surgical management lengthening for permanent - Trial to determine effects of specific proposed surgical correction treatment

DRUG THERAPY
Alcohol has been the best available muscle relaxant but it is not really a practical and nor in the interest of a patients general health. Diazepam is presumed to control spasticity and athetosis
Acting on CNS it lessens anxiety and startle reaction. Since it interfere with ability of concentration, ambulatory patients do not respond well. Works better in younger then 10 years age and total body involvement.

DANTROLENE SODIUM (DANTRIUM)

Ambulatory children with spastic hemiplegia or diplegia show some objective improvement in gait and balance but it produce.
Mental dullness Abnormal liver functions This drug works better in children under 10 years age and with total body involvement.

TIZANIDINE
Centrally acting muscle relaxant that inhibit polysynaptic signal transmission at spinal interneuron level that is responsible for excessive muscle tone, and thus muscle tone is reduce. In addition its muscle-relaxant properties, tizanidine also exerts a moderate central analgesic effect.

Tizanidine is effective in both acute painful muscle spasm and chronic spasticity of spinal and cerebral origin it reduces resistance to passive movements, altercates spasm and clonus and may improve voluntary strength.

Summary

Summary
All the prediction scores to assess results of treatment are used after the age 03 years Because of the Biological factor that:

With growth of nervous system from birth to about 3 years , the functions that were thought to be absent before this age may develop spontaneously with neuronal maturation. Beals

Summary
Better to defer surgery for functional and cosmetic improvement of gait until the child has learned to walk And Child has been walking independently for a year, at least But there are certain exception to this rule: - Prevent eminent subluxation - Prevent expected contracture

Summary
Surgery should not be regarded as a last resort or as something that can always be done when all other methods have failed. Neither should it be unduly staged so that with each birthday the gift is another hospitalization and another period of immobilization. The goal of treatment is a healthy functionally independent person, not a permanent patient.

Summary
Optimum timing for surgery is between 4-8 years Surgery in a CP child to prevent and correct structural changes ought to be performed before the age of 15 (13) years. Pre-operative admission for few days, repeated evaluation & physical occupational therapy, during that period helps to gain confidence of child & child understand the need for continuous rehabilitation (pos-op) for a estimated time i.e not more than 6 months.

Summary
In Upper limb the Surgery in Palsied child is duly useful when: He himself has the full knowledge of fundamentals of this complex entity Lack of knowledge of basics of this complex entity and improper selection of cases for surgery lead to no faith in surgery for CP cases.

Summary
Assessment for Motivational status of patient & his parents is very important before planning for surgery. Before planning surgery, Patient & Parents understanding for OCCUPATIONAL THERAPY, PHYSIOTHERAPY & BRACING is required, as Intensive treatment by these modalities in postoperative rehabilitation is direly needed for long time.

Mental retardation has little if any effect on ability to walk

God has created me . special child It is not my fault

Take care of His creatures He will take care for U

Thankyou