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Knee and Foot Surgery in Adults with Cerebral Palsy

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Knee and Foot Surgery in Adults with Cerebral Palsy Knee and Foot Surgery in Adults with Cerebral Palsy Hank Chambers, MD Professor of Clinical Orthopedic Surgery University of California at San Diego Rady Children’s Hospital I. General Problems: Ambulatory vs Nonambulatory Patients a. Loss of Function b. Loss of Strength c. Loss of walking ability d. Loss of balance e. Skin problems and ulceration f. Shoe and Orthotic wear problems II. Knee Problems a. Femoral Anteversion i. Correction with Femoral Osteotomy b. Internal or External Tibial Torsion i. Correction with Tibial and Fibular Osteotomies c. Hamstring Contractures i. Non Operative Treatment 1. Botulinum Toxins 2. Physical Therapy 3. Bracing ii. Operative Treatment 1. Surgical Lengthening of the hamstrings d. Knee Contractures: Flexion i. Serial Casting ii. Distal Femoral Extension Osteotomy e. Patella Alta and Patellar Fractures i. Patellar tendon distalization ii. Patellar Tendon Reefing f. Genu Varum, Genu Valgum i. Treatment with osteotomies g. Meniscus Tears i. Anterior meniscus tears in patients with recurvatum h. Ligament Injuries i. Acute injuries of ACL, MCL ii. Chronic injuries in patients with genu varum and genu valgum III. Ankle and Foot Problems a. Equinus i. Botulinum Toxins ii. Lengthening of gastrocsoleus muscles iii. Distal Tibial Closing Wedge Osteotomy b. Equinovarus i. Botulinum Toxins ii. Lengthening of gastrocsoleus muscles iii. Role of tendon transfers 1. Split Anterior Tibial Tendon Transfer (SPLATT) 2. Split Posterior Tibial Tendon Transfer (SPOTT) iv. Selective Osteotomies v. Selective Fusions 1. Talonavicular Joint 2. Calcaneoncuboid Joint 3. Talocalcaneal Joint vi. Triple Arthrodesis c. Cavovarus Feet i. Selective Osteotomies ii. Selective Fusions d. Equinovalgus i. Botulinum Toxins ii. Lengthening of the gastrocnemius muscles iii. Selective Osteotomies iv. Selective Fusions e. Calcaneous i. Tenotomy of anterior tibialis tendon ii. Selective Fusions f. Hallux Varus and Dorsal Bunions i. Fusion of the MTP joint g. Lesser Toe Problems i. Hammer Toes ii. Mallet Toes IV. Therapies V. Orthotic Management a. Knee Bracing b. KAFO c. AFO d. SMO e. In Shoe Orthotics f. Shoe Wear alterations Hip and Spine in Adults with Cerebral Palsy M. Wade Shrader, M.D. Pediatric Orthopedic Surgeon Director of Research Phoenix Children’s Hospital University of Arizona College of Medicine I. General Problems of Adult Orthopedic Issues a. Epidemiology of Aging Patients with CP b. Orthopedic Pathophysiology in CP c. What operations should be considered in Adults? d. Who should be performing these procedures? e. Where should they be performed? Childrens Hospital vs Adult Hospital? f. Perioperative mgt issues? g. Outline of Course II. Hip Problems a. Hip dysplasia in CP b. Pathophysiology of spastic hip dysplasia c. Progression of Degenerative Joint Disease d. What is the incidence of hip pain in adults with CP? i. Literature review ii. Do we know true % in today’s world? e. Review of treatment of neuromuscular hip dysplasia in children i. Goals of treatment ii. Surgical procedures 1. Soft tissue procedures 2. Femoral osteotomy iii. Outcomes of treatment f. Surgical treatment for adult hips in CP i. Soft tissue procedures – for hygiene and ease of care ii. Salvage procedures – for pain and DJD g. THA i. Surgical procedure ii. Specific risks in adult CP population iii. Outcomes in the literature iv. Who should do it? v. Where should it be done? h. Resection/Salvage procedures III. Spine Problems a. Scoliosis i. Prevalence ii. Progression of Neuromuscular deformity iii. Delayed decision until young adulthood iv. Surgical management 1. Who should do it? 2. Where should it be done? v. Outcomes 1. QoL improvements 2. Complications b. Spine deformity after spasticity mgt i. After SDR ii. After Baclofen pump c. Spondylolysis and Spondylolisthesis i. Prevalence in CP ii. Conservative treatment iii. Operative treatment d. Lumbar Stenosis i. Progression of scoliosis ii. Progression to radiculopathy/myelopathy iii. Conservative treatment iv. Operative treatment v. e. Cervical Stenosis i. Common in dystonic/athetoid ii. Progression to radiculopathy/myelopathy iii. Conservative treatment iv. Operative treatment References 1: de Moraes Barros Fucs PM, Svartman C, de Assumpção RM, Yamada HH, Simis SD. Surgical technique: Medial column arthrodesis in rigid spastic planovalgus feet. Clin Orthop Relat Res. 2012 May;470(5):1334-43. 2: Horstmann HM, Hosalkar H, Keenan MA. Orthopaedic issues in the musculoskeletal care of adults with cerebral palsy. Dev Med Child Neurol. 2009 Oct;51 Suppl 4:99-105. 3: Borowski A, Synder M, Sibiński M. Subcutaneous Achilles tendon lengthening in the treatment of spastic equinus contracture. Ortop Traumatol Rehabil. 2004;6(6):784-8. 4: Mulier T, Moens P, Molenaers G, Spaepen D, Dereymaeker G, Fabry G. Split posterior tibial tendon transfer through the interosseus membrane in spastic equinovarus deformity. Foot Ankle Int. 1995 Dec;16(12):754-9. 5: Root L. Varus and valgus foot in cerebral palsy and its management. Foot Ankle. 1984 Jan-Feb;4(4):174-9. 6. : Queally JM, Abdulkarim A, Mulhall KJ. Total hip replacement in patients with neurological conditions. J Bone Joint Surg Br. 2009 Oct;91(10):1267-73. 7. Root L. Surgical treatment for hip pain in the adult cerebral palsy patient. Dev Med Child Neurol. 2009 Oct;51 Suppl 4:84-91. 8. Carter DR, Tse B. The pathogenesis of osteoarthritis in cerebral palsy. Dev Med Child Neurol. 2009 Oct;51 Suppl 4:79-83. 9. Van Riet A, Moens P. The McHale procedure in the treatment of the painful chronically dislocated hip in adolescents and adults with cerebral palsy. Acta Orthop Belg. 2009 Apr;75(2):181-8. 10. Schroeder K, Hauck C, Wiedenhöfer B, Braatz F, Aldinger PR. Long-term results of hip arthroplasty in ambulatory patients with cerebral palsy. Int Orthop. 2010 Mar;34(3):335-9. Epub 2009 Apr 22. 11. Knaus A, Terjesen T. Proximal femoral resection arthroplasty for patients with cerebral palsy and dislocated hips: 20 patients followed for 1-6 years. Acta Orthop. 2009 Feb;80(1):32-6. 12. Muthusamy K, Chu HY, Friesen RM, Chou PC, Eilert RE, Chang FM. Femoral head resection as a salvage procedure for the severely dysplastic hip in nonambulatory children with cerebral palsy. J Pediatr Orthop. 2008 Dec;28(8):884-9 13. Lonstein JE, Koop SE, Novachek TF, Perra JH. Result s and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients. Spine. 2012 Apr 1:37 (&): 583-91. 14. Watanabe K, Lenke LG, Daubs MD, Bridwell BKH, Stobbs G, Hensley M. Is spine deformity surgery in patients with spastic cerebral palsy truly beneficial? A patient/parent evaluation. Spine. 2009 Sep 15; 34(20: 2222-32. 15. Murphy KP. Cerebral palsy lifetime care – four musculoskeletal conditions. Dev Med Child Neurol. 2009 Oct; 51 Suppl 4:30-7. 16. Noonan KJ, Jones J, Pierson J, Honhamp NJ, Leverson G. Hip function in adults with severe cerebral palsy. J Bone Joint Surg Am. 2004 Dec; 86-A(12); 2607-13. 17. Fuji T, Yonenbu K, Fukiwara K, Yamashita K, Ebara S, Ono K, Okada K. Cervical radiculopathy or myelopathy secondary to athetoid cerebral palsy. J Bone Joint Surg Am. 1987 Jul; 69(6): 815-21. 18. Majd ME, Muldowny DS, Holt RT. Natural history of scoliosis in the institutionalized adult cerebral palsy population. Spine. 1997 Jul 1; 22(13):1461-6. 19. Madigan RR, Wallace SL. Scoliosis in the institutionalized cerebral palsy population. Spine. 1981 Nov-Dec; 6(6): 583-90. .
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