Orthopaedic Update in Cerebral Palsy:Common Surgical Procedures and Postoperative Rehabilitation

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Orthopaedic Update in Cerebral PalsyCommon
Surgical Procedures and Postoperative
Rehabilitation

• Lael Luedtke, MD
• Sue Murr, PT
• Gillette Childrens Specialty Healthcare

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Cerebral Palsy

• Static Encephalopathy
• Imposed on developing neurologic system and
  skeleton
• results in
• impairment of control of movement and posture

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Types of Cerebral Palsy

• CP classified by
• Tone type
• Distribution of affected areas (extremities,
  trunk, head)

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Tone Types and Movement Disorders

• Spasticity
• Athetosis
• Rigidity
• Ataxia
• Hypotonia
• Mixed

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Distribution

• Hemiplegia
• Monoplegia
• Diplegia
• Quadriplegia
• Triplegia
• Double Hemiplegia

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Cerebral PalsySpastic Quadriplegia
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Spastic Quadriplegia

• Preoperative Evaluation
• Examination Based
• Issues
• Hygiene
• Seating
• Standing
• Shoe Wear

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Spastic Quadriplegia

• Areas of Orthopaedic Concern
• Spine
• Hips
• Knees
• Feet/Legs
• Upper Extremity Caveat

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Spastic Quadriplegia - Spine

• Neuromuscular Scoliosis
• Not generally responsive to bracing
• Relentlessly progressive
• Deformity in both sagittal and coronal planes
• Surgical intervention indicated when curve
  approaches 45º

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Spastic Quadriplegia - Spine

• Surgical treatment is usually fusion
  (arthrodesis) of high thoracic spine to sacrum
• Surgical Options
• Posterior Approach Only
• Anterior plus Posterior Approaches

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Spastic Quadriplegia - Hip

• Subluxation
• Femoral head partially losing contact with
  acetabulum
• Dislocation
• Femoral head completely disengaged from
  acetabulum

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Spastic Quadriplegia - Hip

• Subluxation
• Usually progresses to dislocation
• Evident at about 5 years of age
• Combination of femoral neck valgus and persistent
  anteversion PLUS soft tissue contractures PLUS
  deformity of acetabulum

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Spastic Quadriplegia - Hip

• Subluxation Treatment
• Must treat everything contributing to deformity
• otherwise, like Arnold
• you will be back.

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Spastic Quadriplegia - Hip

• Dislocation
• Usually not painful initially, but will become so
• Usually try to reduce but if very stiff and
  chronic, cannot be done
• Significant pelvic obliquity

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Spastic Quadriplegia - Hip

• Dislocation Procedures
• Reduction usually requires same procedures as
  for subluxation
• Proximal Femoral Resection aka Girdlestone no
  guarantee of pain relief

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Spastic Quadriplegia - Hip

• Soft Tissue Contractures
• ADDUCTION FLEXION

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Spastic Quadriplegia - Knee

• Flexion Contractures difficulties with hygiene,
  seating, sleeping
• Treatment soft tissue releases followed by
  splinting at night

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Spastic Quadriplegia - Feet

• Variety of Positions combinations of varus,
  valgus, equinus and calcaneus usually RIGID
• Soft tissue procedures plus bony fusions to keep
  plantigrade for shoe wear and transfers/standing

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Spastic Quadriplegia

• Postoperative Rehabilitation

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Goals of postoperative rehabilitation

• Improved seating and positioning
• Improve comfort
• Maximize use of upper extremities for function

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Goals of postoperative rehabilitation, continued

• Maintain standing as long as possible for bone
  integrity
• Improve or maintain respiratory function

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Immediate Postoperative Care

• Hip spica casts generally used when a pelvic
  osteotomy has been performed
• Transfers are performed by one or two person
  lifts with or without a sliding board.
• Positioning in bed and reclining wheelchair for
  comfort and function

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Physical therapy after cast removal

• Passive mobilization with whirlpool and range of
  motion exercises
• Gradual resumption of developmental activities
• Resume sitting in own wheelchair with necessary
  modifications, especially when leg length
  discrepancy is present
• Resume use of stander

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Spastic Diplegia/Hemiplegia
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Spastic Diplegia/Hemiplegia

• Evaluation is often based on Gait Lab Analysis
• Important that any spasticity modifying
  procedures or drugs be instituted BEFORE gait lab

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Spastic Diplegia/Hemiplegia

• Gait Lab Components
• ROM, Strength and Rotation Assessment
• Motion Sensors (Kinetics and Kinematics)
• EMG
• Oxygen Consumption

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Spastic Diplegia/Hemiplegia

• Procedures performed
• Osteotomies
• Soft Tissue Modifications
• Muscle Transfers/Lengthenings

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Spastic Diplegia/Hemiplegia

• Osteotomies
• Rotational
• Femoral
• Proximal - Varus /- Derotation
• Distal - Extension
• Tibial Derotation
• Os Calcis Lengthening

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Spastic Diplegia/Hemiplegia

• Soft Tissue Modifications
• Contractures about hip, knee, ankle joints
• Laxity patellar tendon advancement

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Spastic Diplegia/Hemiplegia

• Muscle Transfers/Lengthenings
• Rectus Femoris Transfer
• Gastrocnemius Lengthening
• Anterior/Posterior Tibialis Split Transfers

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Spastic Diplegia/Hemiplegia

• Postoperative Rehabilitation

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Spastic Diplegia/Hemiplegia

• Stages of Recovery after surgery
• Healing of bone and soft tissues approximately
  six weeks
• Strengthening of muscles approximately twelve
  weeks
• Retraining of gait up to twelve months

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Physical Therapy Goals and Procedures Initial
Three Weeks

• Prevent stiffness during the period of
  immobilization
• Positioning - supine without pillows, prone
• Passive range of motion - performed by caregiver
  or CPM

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Physical Therapy Goals and Procedures Initial
Three Weeks

• Transfers
• Generally dependent lift or with patient
  assisting with upper extremities

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Physical Therapy Goals and Procedures Three to
Six Weeks

• Range of Motion
• Passive and active assisted with no limitations
• Strengthening
• Isolated exercise and transitional activities
  based upon selective motor control
• Ambulation
• With appropriate assistive device

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Physical Therapy Goals and Procedures Six to
Twelve Weeks

• Range of Motion
• Routine stretching program resumed
• May continue with use of knee immobilizers at
  night

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Physical Therapy Goals and Procedures Six to
Twelve Weeks

• Strengthening
• Two to three times per week
• Resistance training, swimming, biking, horseback
  riding

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Physical Therapy Goals and Procedures Six to
Twelve Weeks

• Ambulation
• Progresses by increasing distance and speed
• Wean from assistive device, may transition to
  Lofstrand crutches or resume independent
  ambulation

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Physical Therapy Goals and Procedures Six to
Twelve Weeks

• Orthoses
• AFO style PLS (posterior leaf spring), solid
  ankle or dynamic AFO, or FRO (floor reaction AFO)

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Discharge from/reduction in Physical Therapy

• Patient has achieved or exceeded pre-operative
  functional status
• Therapy may continue at the same frequency as
  before surgery, or discontinued
• Periodic strengthening, ongoing stretching
  programs and aerobic exercise is beneficial