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 Chairperson Dr. R. S. Jatti
 Presenter Dr. Srinath Gupta
 Brain grossly differentiates into cerebrum
and cerebellum during 1st Trimester of
embryonic life
 Neurons begin to deve...
 First described in 1862, by William John
Little, an orthopedic surgeon who
observed that children with tone and
developm...
 Definition
 Incidence
 Etiology
 Classification
 Management
 Lower Limb Deformities
 Static, non progressive disorder of CNS secondary
to an insult to immature brain, resulting in
varying degrees of motor ...
 2.4-2.7 for every 1000 live births
 Prenatal:
◦ Infection: TORCH Complex, HIV
◦ Cerebral malformation
◦ Obstetrical complication: pre-eclampsia,
eclampsia, ...
 Perinatal:
◦ Prematurity
◦ Low birth weight
◦ Complicated delivery
◦ Asphyxia
◦ Cerebral trauma
◦ Hyperbilirubinemia
◦ B...
 Post natal :
◦ Infections : Meningitis, encephalitis
◦ Head injury
◦ Cerebral anoxia
◦ Aspiration
◦ Asphyxia
◦ Seizures
...
 Because of the wide variability in presentation and
types of cerebral palsy, there is no universally
accepted classifica...
 Monoplegia
 Hemiplegia
 Paraplegia
 Diplegia
 Quadriplegia
 Double Hemiplegia
 Total body
 Spastic
 Athetoid
 Choreiform
 Rigid
 Ataxic
 Hypotonic
 Mixed
 Spastic:
◦ Most common type
◦ Associated with injury to pyramidal tracts in immature
brain
 Athetoid:
◦ Associated with...
 Rigid:
◦ Most hypertonic form
◦ Cogwheel or leadpipe rigidity
 Ataxic:
◦ Very rare
◦ Injury to developing cerebellum
◦ ...
•Bilateral spasticity of legs
•1st noticed when infant begins to crawl-tends to drag the
legs behind more ( commando crawl...
•Arms often more involved than leg-difficulty in
hand manipulation is obvious by 1 yr
•Delayed walking -18-24 months
•Equi...
•Most severe form ,most
common
•All extremities severely
impaired
•High association with MR
and seizures
•Flexion Contract...
 After age 1yr –athetoid movements
become evident
 Speech is affected (slurred, voice
modulation impaired) due to
involv...
 I Has nearly normal gross motor function
 II Walks independently, but has limitations with
running and jumping
 III Us...
 Mental Retardation
 Communication
Disorders
 Behavioral disorder
 Seizures
 Vision Disorders
 Hearing loss
 Somato...
 Gait in cerebral palsy
◦ Idiopathic toe walking
◦ Spastic knee gait
◦ Crouch gait
 Determine grades of muscle strength and selective
control.
 Evaluate muscle tone and determine type.
 Evaluate degree ...
 History
 Examination
 X-ray skull-intracranial calcification
 EEG
 CT/MRI
 Test of hearing ,vision
 IQ test
Achievable goals should be set
The child with CP becomes the adult with CP
Goals based on needs of adults
 Communication ...
 Control of spasticity
 Physical therapy
 Orthotics
 Orthopedic surgery
 Spasticity is present in most patients with CP (65 % )
 When it is reduced patients may :
- perform integrated muscle
m...
 Other oral medicines used in Cerebral Palsy:
◦ Dantrolene
◦ Flexeril
◦ Antiepileptic drugs such as Phenytoin, Sodium Val...
 Conventional PT :
◦ Works on muscles, tendons, and ligaments
 Active exercises
 Passive ROM exercises
 Passive stretc...
Involve parents as much as possible
(even if they resist)
Do not raise false hopes
which could increase frustration
Casting..
Short leg casts are applied with extended toe plates, careful
molding of the heel and metatarsal head control.
F...
Ankle Foot Orthoses (AFO)
 m
Primary deformity : needs treatment
Compensatory deformity : can improve without intervention
Surgery
 Prevent structural...
 Type : spastic
 Extent : hemiplegics / diplegics : good results
quadriplegics : minimal improvement
 Age : 3- 12 years...
 For structural changes : Early
e.g. Hip subluxation , usually <5 years
 To improve function ( gait ) :
defer until walk...
Surgery should not be unduly staged one by
one
( with each birthday )
?ETA ? Hams ? Psoas ? Rectus Femoris
Equinus Crouch ...
 Hip
◦ Flexion contracture
◦ Increased hip addduction/ scissoring
◦ Subluxating or dislocating hip
 Rotational deformiti...
 Adduction and flexion deformity
 Hip at risk
 Hip subluxation
 Hip dislocation
Hip flexion contractures are found most commonly
in patients with spastic diplegia and spastic
quadriplegia.
Flexion contr...
Thomas test
Staheli test
Ely / Rectus Femoris
Test
 Flexion internal rotation deformity should be
differentiated from True Adduction deformity.
 Increased femoral antevers...
 Single-stage multilevel procedures are preferable to
staged single-level procedures because hospitalization,
immobilizat...
 Iliopsoas recession (Skaggs et al technique)
 Iliopsoas release at the Lesser trochanter(Miller
technique)
Iliopsoas tenotomy / lengthening /
recession
 Tenotomy : Should not be done in
ambulatory patients
 Recession : Doesn’t ...
 Most common deformity
 Spasticity in the adductor muscles in cerebral palsy results
in a narrow base of gait and scisso...
 Adductor tenotomy and release
◦ Resection of tendon of adductor longus and anterior half of
addductor brevis and gracili...
 Deformities of the hip in patients with cerebral
palsy range from mild painless subluxation to
complete dislocation with...
 Hip subluxation in patients with cerebral palsy can
be difficult to detect clinically
 Routine clinical and radiographi...
Hip subluxation ( partially out)
Hilgenreiner line
Dislocated Subluxated
50 %
Reimer’s migration
index
Hip subluxation ( partially out )
( > 30 % uncoverage / broken Shenton’s line )
Because early intervention can be very effective in
preventing or delaying the development of dislocation,
considerable wo...
Hip at Risk Hip subluxation
At 2.5 years At 7 years
 Varus Derotational Osteotomy, usually combined
with soft-tissue releases, is indicated for patients
with excessive antev...
 Combined One-Stage Correction of Spastic
Dislocated Hip (San Diego Procedure)
◦ medial approach (soft-tissue release)
◦ ...
 Proximal Femoral Resection
Painful dislocated
> 1 year
Surgical resection
 Hip Arthrodesis
The ideal candidate is a patient with unilateral
disease and no spinal involvement. Hip arthrodesis
may ...
 Deformities of the knee rarely occur in isolation
 The hip and the knee are tightly coupled because of
the muscles that...
 Flexion Deformity
 Recurvatum of the Knee
 Knee Valgus
 Patella Alta
 Most common knee deformity in patients with
cerebral palsy and frequently occurs in ambulatory
children
 Crouching gait.
 Straight leg raising
◦ Angle< 70 … Indication
 The Hamstring Test
◦ Holt’s method
◦ Popliteal Angle< 135 - Indication
 Fractional Lengthening
of Hamstring Tendons
 Distal Transfer of Rectus Femoris
 Combined Hamstring Lengthening and
Quadriceps Shortening along with posterior
capsule release
Hip flexion Deformity
increases after
hamstring release
Better to transfer
hamstring insertion
to keep hip extended
 Caused by Quadriceps spasticity or long standing
Knee FFD.
 Can lead to repeated to micro trauma to patellar
tendon and...
 DEFORMITIES
◦ Equinus Deformity
◦ Varus or Valgus Deformity
 Equinovarus Deformity
 Equinovalgus Deformity
◦ Calcaneus...
 Most common foot
deformity in patients
with cerebral palsy
 It is an increased plantar
flexion due to a plantar
flexion...
 Toe-walking patients must be considered as two
different groups:
◦ equinus patients
◦ as a consequence of crouch at the ...
 Clinical examination..
Inability to fully dorsiflex the ankle
 The Silverskiold test:
If the ankle can be passively dor...
The Silfverskiold test
 Dynamic :
Treat by :
Bracing
Spasticity reduction
Surgery
 Fixed :
Treat by :
Serial casting
Surgery
 Open Lengthening of the
Achilles Tendon
 Z-Plasty Lengthening of the Achilles Tendon
 Percutaneous Lengthening of the Achilles Tendon
Vulpius technique.. Strayer procedure
Baker technique
(tongue-in-groove)
 Diplegic patients typically have internally rotated
and adducted hips, flexed knees, and external
rotation deformity of ...
 Muscle imbalance in which
the invertors of the foot over
power the evertors, most
commonly Tibialis post.
 Gastrocnemiu...
The confusion test:
The patient flexes the hip against
resistance
If supination of the forefoot is seen, then
anterior tib...
 It also is important to determine whether or not the
deformity is flexible and correctable or rigid because
patients wit...
 Lengthening of the Posterior Tibial Tendon
◦ Z-Plasty Lengthening of the Posterior Tibial Tendon
◦ Step-Cut Lengthening ...
 Split Tendon
Transfers
◦ Split posterior tibial
tendon transfer
It is one of the most common
procedures for equinovarus
...
◦ Split anterior tibial tendon transfer
The lateral one-half of anterior tibialis is detached from its
insertion.
Passed b...
Split transfer of tibialis anterior tendon
 Heel varus will respond to calcaneal osteotomy.
 If the deformity is severe, and with rigid
component of mid foot supin...
 Occurs in up to 25% of patients with cerebral palsy.
and most common in older diplegic or quadriplegic
patients.
 Can b...
 Bony surgery is the only predictable alternative
for full and lasting correction.
 Surgical options are…
I. The Grice e...
 Modifications to the original procedure:
 Fibular graft was changed to iliac crest graft.
 Using internal fixation to ...
Advantage: preserve
joint motion of sub
talar joint.
Results have been very
good.
Contraindications:
severe rigid valgus
d...
 Treatment of choice for rigid symptomatic Pes valgus in adolescent
with cerebral palsy.
 Resecting the subtalar, calcan...
Triple arthrodesis for Pes valgus treatment
 It is a rare deformity.
 The first metatarsal head is elevated, but
the great toe is plantar flexed.
 Surgical rebalan...
 Develops in cerebral palsy patients in response to a Equino valgus deformity of the
hind foot.
 There is a progressive ...
Hallux valgus in 14 yrs. Old girl with cerebral palsy.
Treated with metatarsophalangeal fusion.
 Usually caused by femoral ante-
version
 Internal tibial torsion adds to Intoeing
 Not related to spasticity of intern...
 Anteversion rotates Greater Trochanter
posteriorly
 On stance phase need Abductor power
 Abductor power optimized when...
 Severe femoral anteversion, with loss of all
external rotation.
 Dynamic in-toeing causing gait abnormalities.
 Dynami...
THANK YOU…!!
Presentation of cerebral palsy
Presentation of cerebral palsy
Presentation of cerebral palsy
Presentation of cerebral palsy
Presentation of cerebral palsy
Presentation of cerebral palsy
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Presentation of cerebral palsy

Orthopaedic management principles of CP

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Presentation of cerebral palsy

  1. 1.  Chairperson Dr. R. S. Jatti  Presenter Dr. Srinath Gupta
  2. 2.  Brain grossly differentiates into cerebrum and cerebellum during 1st Trimester of embryonic life  Neurons begin to develop in 2nd trimester  By end of 2nd trimester all neurons are formed and any damage occurring now is irreversible  Synaptic connections occur in 3rd trimester
  3. 3.  First described in 1862, by William John Little, an orthopedic surgeon who observed that children with tone and developmental abnormalities often had prolonged labor, prematurity or breech delivery  Cerebral Palsy was known as Little’s Disease for decades.  The term cerebral Palsy originated with William Osler and Sigmund Freud  Static Encephalopathy has been used interchangeably with cerebral palsy
  4. 4.  Definition  Incidence  Etiology  Classification  Management  Lower Limb Deformities
  5. 5.  Static, non progressive disorder of CNS secondary to an insult to immature brain, resulting in varying degrees of motor milestone delay and dysfunction  CP is a disorder of tone, posture or movement  It results in paralysis, weakness, in coordination or abnormal movement
  6. 6.  2.4-2.7 for every 1000 live births
  7. 7.  Prenatal: ◦ Infection: TORCH Complex, HIV ◦ Cerebral malformation ◦ Obstetrical complication: pre-eclampsia, eclampsia, abruptio placentae, placenta previa, placental infarction ◦ Maternal diseases ◦ Abuse of drugs
  8. 8.  Perinatal: ◦ Prematurity ◦ Low birth weight ◦ Complicated delivery ◦ Asphyxia ◦ Cerebral trauma ◦ Hyperbilirubinemia ◦ Blood incompatibilities ◦ Infections: Herpes simplex, meningitis ◦ Severe hypoglycemia
  9. 9.  Post natal : ◦ Infections : Meningitis, encephalitis ◦ Head injury ◦ Cerebral anoxia ◦ Aspiration ◦ Asphyxia ◦ Seizures ◦ Near drowning ◦ Cardiac arrest ◦ Cerebrovascular accidents ◦ Sickle cell anaemia ◦ Vascular malformations
  10. 10.  Because of the wide variability in presentation and types of cerebral palsy, there is no universally accepted classification scheme.
  11. 11.  Monoplegia  Hemiplegia  Paraplegia  Diplegia  Quadriplegia  Double Hemiplegia  Total body
  12. 12.  Spastic  Athetoid  Choreiform  Rigid  Ataxic  Hypotonic  Mixed
  13. 13.  Spastic: ◦ Most common type ◦ Associated with injury to pyramidal tracts in immature brain  Athetoid: ◦ Associated with injury to extrapyramidal tracts ◦ Dyskinetic purposeless movements ◦ Dystonia or hypotonia can occur with athetoid cerebral palsy  Choreiform: ◦ Continual purposeless movements of wrists,fingers,toes and ankles
  14. 14.  Rigid: ◦ Most hypertonic form ◦ Cogwheel or leadpipe rigidity  Ataxic: ◦ Very rare ◦ Injury to developing cerebellum ◦ Disturbance of coordinated movement viz. walking ◦ Characterized by weakness, in-coordination, a wide based gait, and trouble with fine and rapid movements.  Hypotonic: ◦ Passing stage in spastic or ataxic cerebral palsy  Mixed: ◦ Signs of pyramidal and extrapyramidal deficits
  15. 15. •Bilateral spasticity of legs •1st noticed when infant begins to crawl-tends to drag the legs behind more ( commando crawl) •Severe spasticity –application of diaper is difficult due to excess adduction of hips •Brisk reflexes, ankle clonus •Scissoring posture of lower extremity when suspended by axilla •Walking tiptoes, disuse atropy ,impaired growth of lower extremity •Intellectual development normal •Minimal seizures •CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibres •All spastic types characterized by toe walking, a crouched gait, and flexed knee, scissoring
  16. 16. •Arms often more involved than leg-difficulty in hand manipulation is obvious by 1 yr •Delayed walking -18-24 months •Equinovarus deformity of foot, walks on tip toes because of increased tone •Affected upper limb has dystonic posture when child runs •Deep tendon reflexes increased, ankle clonus, Babinski sign + •1/3rd have seizure disorder •25% have MR •CT/MRI- atrophic cerebral hemisphere with dilated lateral ventricle contralateral to the affected side
  17. 17. •Most severe form ,most common •All extremities severely impaired •High association with MR and seizures •Flexion Contractures of knees and elbows
  18. 18.  After age 1yr –athetoid movements become evident  Speech is affected (slurred, voice modulation impaired) due to involvement of oropharyngeal muscles  Upper motor neuron signs –not present  Seizure uncommon  Intellect –preserved  Characterized by an exaggerated step, hip and knee hyperextension, a backwards lean, and shoulder girdle and trunk extension.
  19. 19.  I Has nearly normal gross motor function  II Walks independently, but has limitations with running and jumping  III Uses assistive devices to walk and wheelchair for long distances  IV Has ability to stand for transfers, but minimal walking ability; depends on wheelchair for mobility  V Lacks head control, can’t sit independently, is dependent for all aspects of care
  20. 20.  Mental Retardation  Communication Disorders  Behavioral disorder  Seizures  Vision Disorders  Hearing loss  Somatosensation (skin sensation, body awareness)  Temperature instability  Nutrition  Drooling  Dentition problems  Neurogenic bladder  Neurogenic bowel  Gastroesophageal reflux  Dysphagia  Autonomic dysfunction
  21. 21.  Gait in cerebral palsy ◦ Idiopathic toe walking ◦ Spastic knee gait ◦ Crouch gait
  22. 22.  Determine grades of muscle strength and selective control.  Evaluate muscle tone and determine type.  Evaluate degree of deformity / contracture at each joint.  Assess linear, angular and torsional deformities of spine, long bones, hands and feet.  Appraise balance, equilibrium and standing / walking posture.
  23. 23.  History  Examination  X-ray skull-intracranial calcification  EEG  CT/MRI  Test of hearing ,vision  IQ test
  24. 24. Achievable goals should be set The child with CP becomes the adult with CP Goals based on needs of adults  Communication : verbal / nonverbal  Mobility  Walking  Activity of daily living (ADL) feeding, dressing, toileting, bathing  Turn focus of parents from the disease to the goal-oriented approach
  25. 25.  Control of spasticity  Physical therapy  Orthotics  Orthopedic surgery
  26. 26.  Spasticity is present in most patients with CP (65 % )  When it is reduced patients may : - perform integrated muscle movement - develop muscle strength - function at a higher level  Approaches : • Selective dorsal rhizotomy • Intrathecal baclofen • Botulinum-A toxin
  27. 27.  Other oral medicines used in Cerebral Palsy: ◦ Dantrolene ◦ Flexeril ◦ Antiepileptic drugs such as Phenytoin, Sodium Valproate, Carbamazepine, etc.
  28. 28.  Conventional PT : ◦ Works on muscles, tendons, and ligaments  Active exercises  Passive ROM exercises  Passive stretching  Bracing
  29. 29. Involve parents as much as possible (even if they resist) Do not raise false hopes which could increase frustration
  30. 30. Casting.. Short leg casts are applied with extended toe plates, careful molding of the heel and metatarsal head control. For a period of time varies but usually a minimum of 6 weeks. and is followed by the use of orthoses. There is a limited role for casting in patients with cerebral palsy. Orthoses.. Can be helpful in improving gait in ambulatory patient with cerebral palsy. Ankle-foot orthoses are most commonly prescribed to assist the child with positioning of the ankle and foot during gait.
  31. 31. Ankle Foot Orthoses (AFO)
  32. 32.  m
  33. 33. Primary deformity : needs treatment Compensatory deformity : can improve without intervention Surgery  Prevent structural changes - usually early  Improve function - usually later Distinguish between
  34. 34.  Type : spastic  Extent : hemiplegics / diplegics : good results quadriplegics : minimal improvement  Age : 3- 12 years  IQ : good  Good upper limb function : for walking  Underlying muscle power : not weak  Walker / non-walker : surgery hardly changes state but improves gait
  35. 35.  For structural changes : Early e.g. Hip subluxation , usually <5 years  To improve function ( gait ) : defer until walking ( independently / with aids ) until gait pattern develops and can be assessed walking : 18 – 21 months in hemiplegia 3 – 4 years in spastic diplegia  Optimum time of lower extremity surgery 5 – 7 years: can analyze and observe gait pattern
  36. 36. Surgery should not be unduly staged one by one ( with each birthday ) ?ETA ? Hams ? Psoas ? Rectus Femoris Equinus Crouch Flexion Stiff Knee Ok
  37. 37.  Hip ◦ Flexion contracture ◦ Increased hip addduction/ scissoring ◦ Subluxating or dislocating hip  Rotational deformities of femur and tibia  Knee  Foot ◦ Equinus ◦ Equinovarus ◦ Pes valgus ◦ Ankle valgus ◦ Hallux valgus ◦ Dorsal Bunion
  38. 38.  Adduction and flexion deformity  Hip at risk  Hip subluxation  Hip dislocation
  39. 39. Hip flexion contractures are found most commonly in patients with spastic diplegia and spastic quadriplegia. Flexion contracture is due to increased tone in the hip flexors (primarily the iliopsoas) and relative weakness of the hip extensors (such as the gluteal muscles) The contracture is identified during the physical examination by performing the Thomas and Staheli maneuvers.
  40. 40. Thomas test Staheli test
  41. 41. Ely / Rectus Femoris Test
  42. 42.  Flexion internal rotation deformity should be differentiated from True Adduction deformity.  Increased femoral anteversion when combined with crouch at the knee can produce the appearance of scissoring which termed as pseudo adduction  Adductor surgery will be ineffective in improving the child’s ability to walk when the narrow base of gait is secondary to pseudo adduction.
  43. 43.  Single-stage multilevel procedures are preferable to staged single-level procedures because hospitalization, immobilization, and rehabilitation time and the number of anesthetic exposures are decreased  Hip flexion contractures from 15 to 30 degrees usually are treated with psoas lengthening  Contractures of more than 30 degrees may require more extensive releases of the rectus femoris, sartorius, and tensor fasciae latae and the anterior fibers of the gluteus minimus and medius, in addition to the iliopsoas
  44. 44.  Iliopsoas recession (Skaggs et al technique)
  45. 45.  Iliopsoas release at the Lesser trochanter(Miller technique)
  46. 46. Iliopsoas tenotomy / lengthening / recession  Tenotomy : Should not be done in ambulatory patients  Recession : Doesn’t cause excessive hip flexion weakness  Lengthening (z plasty) : best / easy /satisfactory in ambulating patients no risk of too much weakening of flexion power
  47. 47.  Most common deformity  Spasticity in the adductor muscles in cerebral palsy results in a narrow base of gait and scissoring, hip subluxation, and, in severely affected children, difficulty with perineal hygiene
  48. 48.  Adductor tenotomy and release ◦ Resection of tendon of adductor longus and anterior half of addductor brevis and gracilis ,if required ◦ Avoid neurectomy of ant. branch of obturator nerve
  49. 49.  Deformities of the hip in patients with cerebral palsy range from mild painless subluxation to complete dislocation with joint destruction, pain, and impaired mobility  In most patients, the hip is normal at birth, and radiographic changes typically become apparent between 2 and 4 years of age.
  50. 50.  Hip subluxation in patients with cerebral palsy can be difficult to detect clinically  Routine clinical and radiographic examinations should be done every 6 months  A practical radiographic method for quantifying the amount of hip subluxation present, which was described by Reimers as the “migration percentage.”
  51. 51. Hip subluxation ( partially out) Hilgenreiner line Dislocated Subluxated 50 % Reimer’s migration index
  52. 52. Hip subluxation ( partially out ) ( > 30 % uncoverage / broken Shenton’s line )
  53. 53. Because early intervention can be very effective in preventing or delaying the development of dislocation, considerable work has been done to identify hips at risk
  54. 54. Hip at Risk Hip subluxation At 2.5 years At 7 years
  55. 55.  Varus Derotational Osteotomy, usually combined with soft-tissue releases, is indicated for patients with excessive anteversion and valgus deformity of the proximal femur and a hip that is either subluxated or dislocated
  56. 56.  Combined One-Stage Correction of Spastic Dislocated Hip (San Diego Procedure) ◦ medial approach (soft-tissue release) ◦ anterior approach (open reduction) ◦ lateral approach (femoral osteotomy) ◦ anterior approach (pericapsular pelvic osteotomy)
  57. 57.  Proximal Femoral Resection Painful dislocated > 1 year Surgical resection
  58. 58.  Hip Arthrodesis The ideal candidate is a patient with unilateral disease and no spinal involvement. Hip arthrodesis may be preferable in ambulatory patients because it allows weight bearing, in contrast to proximal femoral resections.
  59. 59.  Deformities of the knee rarely occur in isolation  The hip and the knee are tightly coupled because of the muscles that cross both joints, the “two-joint muscles.”
  60. 60.  Flexion Deformity  Recurvatum of the Knee  Knee Valgus  Patella Alta
  61. 61.  Most common knee deformity in patients with cerebral palsy and frequently occurs in ambulatory children  Crouching gait.
  62. 62.  Straight leg raising ◦ Angle< 70 … Indication  The Hamstring Test ◦ Holt’s method ◦ Popliteal Angle< 135 - Indication
  63. 63.  Fractional Lengthening of Hamstring Tendons
  64. 64.  Distal Transfer of Rectus Femoris
  65. 65.  Combined Hamstring Lengthening and Quadriceps Shortening along with posterior capsule release
  66. 66. Hip flexion Deformity increases after hamstring release Better to transfer hamstring insertion to keep hip extended
  67. 67.  Caused by Quadriceps spasticity or long standing Knee FFD.  Can lead to repeated to micro trauma to patellar tendon and quadriceps tendon and stress fractures of patella and tibial tubercle.  Usually painless, so intervention is not required.  Correction of FFD of knee with hamstring lengthening causes improvement.
  68. 68.  DEFORMITIES ◦ Equinus Deformity ◦ Varus or Valgus Deformity  Equinovarus Deformity  Equinovalgus Deformity ◦ Calcaneus Deformity ◦ Cavus Deformity ◦ Forefoot Adduction Deformity ◦ Hallux Valgus Deformity ◦ Claw Toes
  69. 69.  Most common foot deformity in patients with cerebral palsy  It is an increased plantar flexion due to a plantar flexion contracture or dynamic plantar flexion due to over activity of the gastrocsoleus during gait
  70. 70.  Toe-walking patients must be considered as two different groups: ◦ equinus patients ◦ as a consequence of crouch at the hip and knee with natural ankle.  Cerebral palsy must be differentiated from:  Idiopathic toe walking as a congenital short Achilles tendon  Muscular dystrophy (as Duchenne’s)produces toe walking.
  71. 71.  Clinical examination.. Inability to fully dorsiflex the ankle  The Silverskiold test: If the ankle can be passively dorsiflexed with the knee bent to 90 degree but cannot be dorsiflexed with the knee extended it is believed that the gastrocnemius is tight, but the soleus is not contracted  This test is used to determine which type of surgical lengthening to perform
  72. 72. The Silfverskiold test
  73. 73.  Dynamic : Treat by : Bracing Spasticity reduction Surgery  Fixed : Treat by : Serial casting Surgery
  74. 74.  Open Lengthening of the Achilles Tendon
  75. 75.  Z-Plasty Lengthening of the Achilles Tendon
  76. 76.  Percutaneous Lengthening of the Achilles Tendon
  77. 77. Vulpius technique.. Strayer procedure
  78. 78. Baker technique (tongue-in-groove)
  79. 79.  Diplegic patients typically have internally rotated and adducted hips, flexed knees, and external rotation deformity of the tibia. This combination of deformities causes the foot to assume a valgus position.  In hemiplegic patients, the internally rotated thigh with the knee coming to full extension in stance phase causes the foot to internally rotate and produce a varus deformity
  80. 80.  Muscle imbalance in which the invertors of the foot over power the evertors, most commonly Tibialis post.  Gastrocnemius contributing equinus  Surgery is indicated to 1. Improve foot contact. 2. Relieve pain. 3. Relieve skin changes
  81. 81. The confusion test: The patient flexes the hip against resistance If supination of the forefoot is seen, then anterior tibialis is contributing to equinovarus deformity .When dorsiflexion is seen without supination, the deformity is less likely to respond to surgery on the anterior tibialis
  82. 82.  It also is important to determine whether or not the deformity is flexible and correctable or rigid because patients with flexible deformities are more likely to be successfully treated nonoperatively with orthotics and shoe modifications and operatively with soft-tissue procedures such as tendon lengthenings, releases, or transfers (usually of the abnormally active muscle)  Patients with rigid varus deformities generally require bone procedures, such as calcaneal osteotomy.
  83. 83.  Lengthening of the Posterior Tibial Tendon ◦ Z-Plasty Lengthening of the Posterior Tibial Tendon ◦ Step-Cut Lengthening of the Posterior Tibial Tendon ◦ Intramuscular lengthening of the Posterior Tibial Tendon
  84. 84.  Split Tendon Transfers ◦ Split posterior tibial tendon transfer It is one of the most common procedures for equinovarus deformity treatment. The posterior one-half of the posterior tibialis tendon is rerouted posterior to tibia and woven into the peroneus brevis tendon.
  85. 85. ◦ Split anterior tibial tendon transfer The lateral one-half of anterior tibialis is detached from its insertion. Passed beneath the extensor retinaculum. Inserted through a bone tunnel into the cuboid. Foot is positioned in 5-10 deg. of dorsiflexion. Known as the Rancho procedure when done in combination with posterior tibialis lengthening.
  86. 86. Split transfer of tibialis anterior tendon
  87. 87.  Heel varus will respond to calcaneal osteotomy.  If the deformity is severe, and with rigid component of mid foot supination… Triple arthrodesis should be performed.  Even with bony procedures, muscle imbalance must be corrected.
  88. 88.  Occurs in up to 25% of patients with cerebral palsy. and most common in older diplegic or quadriplegic patients.  Can be caused by spastic peroneal muscles, weakness of the p.tibialis and a tight gastrocsoleus.  Radiographs should be obtained in standing position for the foot and ankle.  Conservative treatment should vigorously pursued.. shoe inserts and orthoses may be adequate to relive pain and avoiding surgery.
  89. 89.  Bony surgery is the only predictable alternative for full and lasting correction.  Surgical options are… I. The Grice extra- articular arthrodesis. II. Lateral column (calcaneal neck) lengthening. III. Calcaneal osteotomy. IV. Triple arthrodesis.
  90. 90.  Modifications to the original procedure:  Fibular graft was changed to iliac crest graft.  Using internal fixation to keep the position of the subtalar joint in combination with cancellous iliac crest graft.
  91. 91. Advantage: preserve joint motion of sub talar joint. Results have been very good. Contraindications: severe rigid valgus deformity.
  92. 92.  Treatment of choice for rigid symptomatic Pes valgus in adolescent with cerebral palsy.  Resecting the subtalar, calcaneocuboid, talonavicular joints.  Indications: 1. Pain 2. Skin ulceration over the talar head. 3. Deformity interfering with ambulation in child with deformity not amenable to osteotomy.  Satisfactory outcomes are found when deformity is well corrected.  Degenerative changes have been documented in the ankle joint at an average of 18yrs.following arthrodesis in 43% of the pediatric population.
  93. 93. Triple arthrodesis for Pes valgus treatment
  94. 94.  It is a rare deformity.  The first metatarsal head is elevated, but the great toe is plantar flexed.  Surgical rebalance depends on… Transfer of the flexor tendon to the extensor. Or flexor tenotomy. Or by transferring of the flexor hallucis brevis to the metatarsal neck Or by all that in combination with closing wedge plantar flexion osteotomy of first metatarsal.
  95. 95.  Develops in cerebral palsy patients in response to a Equino valgus deformity of the hind foot.  There is a progressive eversion and abduction of foot because of peroneus longus is spastic.  The toe is pushed laterally as weight is borne by the everted foot.  The big toe comes to lie beneath the second toe, and the first metatarsal head becomes uncovered and painful bunion develops.  When this deformity is mild, surgical treatment of Pes valgus will halt the progression of toe deformity.  Bleck& Goldner described soft tissue realignment including: Release of the adductor hallucis t. and lateral capsulotomy of the first metatarsophalangeal joint. combined with first metatarsal and proximal phalangeal osteotomy.  McKeveer technique:  First metatarsophalangeal fusion.  That led to better results with less recurrence than soft tissue realignment.  Preferred position for fusion is 15-25 deg. Of dorsiflexion and slight valgus.
  96. 96. Hallux valgus in 14 yrs. Old girl with cerebral palsy. Treated with metatarsophalangeal fusion.
  97. 97.  Usually caused by femoral ante- version  Internal tibial torsion adds to Intoeing  Not related to spasticity of internal rotators  If severe : Derotation osteotomy Delay to late childhood if possible  Derotation osteotomy of femur might cause tightening of medial hamstrings ( might need lengthening )
  98. 98.  Anteversion rotates Greater Trochanter posteriorly  On stance phase need Abductor power  Abductor power optimized when Greater Trochanter is lateral not posterior  Internal rotation in stance phase brings Greater Trochanter laterally
  99. 99.  Severe femoral anteversion, with loss of all external rotation.  Dynamic in-toeing causing gait abnormalities.  Dynamic in-toeing causing secondary foot deformity.  Usually not before 8-10 years.
  100. 100. THANK YOU…!!

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