Orthopaedic Update in Cerebral

Palsy:Common Surgical

Procedures and Postoperative

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

Cerebral Palsy
Static Encephalopathy Imposed on developing neurologic system and skeleton

results in impairment of control of movement and posture

Types of Cerebral Palsy

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

Tone Types and Movement Disorders

Spasticity Athetosis Rigidity Ataxia Hypotonia Mixed

Distribution
Hemiplegia Monoplegia Diplegia Quadriplegia Triplegia Double Hemiplegia

Cerebral Palsy Spastic Quadriplegia

Spastic Quadriplegia
Preoperative Evaluation: Examination Based Issues:
Hygiene Seating Standing Shoe Wear

Spastic Quadriplegia
Areas of Orthopaedic Concern: Spine Hips Knees Feet/Legs
Upper Extremity Caveat

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 45

Spastic Quadriplegia Spine

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

Spastic Quadriplegia - Hip

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

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

Spastic Quadriplegia - Hip

Subluxation Treatment: Must treat everything contributing to deformity otherwise, like Arnold

you will be back.

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

Spastic Quadriplegia - Hip

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

Spastic Quadriplegia - Hip

Soft Tissue Contractures ADDUCTION & FLEXION

Spastic Quadriplegia - Knee

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

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

Spastic Quadriplegia
Postoperative Rehabilitation

Goals of postoperative rehabilitation

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

Goals of postoperative rehabilitation, continued

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

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

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

Spastic Diplegia/Hemiplegia

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

Spastic Diplegia/Hemiplegia
Gait Lab Components: ROM, Strength and Rotation Assessment Motion Sensors (Kinetics and Kinematics) EMG Oxygen Consumption

Spastic Diplegia/Hemiplegia
Procedures performed: Osteotomies Soft Tissue Modifications Muscle Transfers/Lengthenings

Spastic Diplegia/Hemiplegia
Osteotomies Rotational:
Femoral
Proximal - Varus +/- Derotation Distal - Extension

Tibial Derotation Os Calcis Lengthening

Spastic Diplegia/Hemiplegia
Soft Tissue Modifications: Contractures: about hip, knee, ankle joints Laxity: patellar tendon advancement

Spastic Diplegia/Hemiplegia
Muscle Transfers/Lengthenings: Rectus Femoris Transfer Gastrocnemius Lengthening Anterior/Posterior Tibialis Split Transfers

Spastic Diplegia/Hemiplegia
Postoperative Rehabilitation

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

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

Physical Therapy Goals and Procedures: Initial Three Weeks

Transfers
Generally dependent lift or with patient assisting with upper extremities

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

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

Physical Therapy Goals and Procedures: Six to Twelve Weeks

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

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

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)

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