Ascending Functional Approach of the Skeletal System

F. Landauer

University Clinic of Orthopedics (PMU) Salzburg General Hospital Muellner Hauptstr. 48, 5020 Salzburg Austria Balancing of the spine

Coronary Plane: Balancing of the spine over the disc L5-S1 (pelvis) without and in the brace

Sagittal plane: Balancing to the plumb line: sacrum (pelvis),lumbar lordosis, thoracal kyphosis, cervical lordosis

Horizontal plane: Rotation of the spine segments

Coronary plane (horizontal balancing of the sacrum) Leg length discrepancy (LLD) real (insoles, adapting of the shoes, orthoprostheses, etc.) functianal (physiotherapy, partial equalization of LLD, etc.) Sitting position non walker

Sagittal plane (balancing of the sacrum) Balancing of the lumbosacral segment + cranial without and in the brace Free movement of the hip

Horizontal plane (rotational balancing of the sacrum) Balancing of the lumbosacral segment + cranial without and in the brace

Early onset scoliosis Adolescent scoliosis Adult scoliosis

gray zone

Age

KING-classification LENKE-classification

The sacrum is always horizontal

Compensation with an insole Heel Pad

It do´s not look like a typical AIS

It looks like a AIS Equalization of the leg length discrepancy

<1.5cm → insoles etc.

1cm to 2cm → Epiphysiodesis

>2cm → Leg-lengthening

The x-ray (upright ap-view) of 250 patients assigned with the diagnosis “idiopathic scoliosis” were retrospectively examined to leg length difference >1.0 cm.

First question: How many patients showed scoliosis as a compensation mechanism of leg-length discrepancy? How many needed epiphysiodesis in differences >1.5cm.

Second question: What causes of leg length discrepancy are found and what are the therapeutic consequences?

4 Patients with neurological findings were excluded.

First question:

In 5 cases of the 250 examined assigned patients, scoliosis was a compensation mechanism of the leg length discrepancy. Leg length compensation (insole) was sufficient for spinal correction.

In 3 cases with a leg length difference >1.5 cm a temporary epiphysiodesis was indexed.

remove

15 month´s later

Endresult

X-ray +1cm on the left

Pathological findings in the lower extremity Malformation 1 showed hypoplasia of the fibula (type 1A Achtermann and Kalamachi) 1 patient with hypoplastic femur (type IX by Pappas) could be diagnosed Trauma 1 patient had a femoral fracture in the early childhood, 1 patient suffered from an injury of the growth plate of the femur Tumor like leasion 1 patient showed a fibrous dysplasia + myxoma

Hormonal problems 3 patients had ftreatment with hormons

© Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 14 Second question: pathological findings Pathological findings at the hip 2 cases a chronic slipped capital femoral epiphysis could be found and they needed surgical intervention. Additional hormonal causes as Hashimoto thyroiditis and delayed puberty were conspicuous.

1 patient a femoral head deformity after SCFE could be diagnosed and was corrected.

2 undiagnosed Perthes disease could be found.

Many other diagnoses can influenze the lower extremities

4 patients with first diagnosed neurological findings are excluded.

In 15 cases of 246 patients leg-length-discrepancy >1cm could be found and pathological findings differentiated.

Hypoplasia of the fibula Type 1A Achtermann and Kalamachi

Future:

Lengthening + Corretion of the with tibia insole ball in socket

What is the reason for the LLD ?

We are not proud about the correction!

Insole on the left +1.5cm

Fibrous dysplasia

Insole on the left +1.5cm

MRI

Myxoma Th10-11

Insole on the left +1.5cm

Fibrous dysplasia (Mb Jaffe-Lichtenstein) (monostotic or polyostotic)

McCune-Albright Syndrome (with hormonal findings like hyperpigmentation, pubertas praecox)

Mazabraud Syndrome Fibrous dysplasia + Myxoma

Mutation of the G-protein

S.L.27.2.01 H.S.17.3.1996 R.J.1.6.2008

Defect of the growth plate

Defect of the Femur

with Hypoplasia shoelift right

Message: LLD is an indicator for different diseases: Malformation Pathologie of the growth plate: Trauma, hypoplasia, misalignement, Perthes disease, epiphysiolysis (hormonal disease), etc. Tumor like leasions (genetic disease), etc. Scoliosis

(The foot is a very good indicator for neurological findings)

LLD can be treated very easy by Epiphysiodesis

In case of scoliosis: Have an eye on the lower extemities.

It reduces the number of „idiopathic“ scoliosis.

The connection between hip and the lumbar spine: Hip: Hip dysplasia Perthes disease Slipped Capital Femoral Epiphysiolysis Arthritis ec. Lumbar spine: Malformation Spondylolyis / -listhsis Degeneration: rigidity / instability etc. The ventral shape: Adipositas, etc. Neuromuscular disease Hip flexion contracture The foot as an indicator, etc.

R.A.21.2.74

Tripleosteotomie (Tönnis)

LLD: right +2cm Retrotorsion of the femur

Norm: 12° Antetorsion

NORM 12° Anteversion

F.A.9.4.51 P.H.9.7.42

Funktional LLD

Case 1 Case 2 Perthes disease

Hip adduction LLD Lumbar deviation

Epiphysiodesis

SCFE Slipped Capital Femoral Epiphysis

Subcapital osteotomie

Hashimoto thyreoiditis

Cobb-angle

Risser III

Hashimoto thyreoiditis

© Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 30 Malalignement + Hormons S.G.24.92 Tibia valga Scoliosis Spondylolisthesis Pubertas tarda (Hormonal treatment)

Scoliosis Pecten excavatum Treatment with growth hormon

What is the difference?

Operation of the rip-deformity Brace

The model shows how the boundary conditions affect the critical load of a slender column. Notice that each of the columns are identical, apart from the boundary conditions.

Center of rotation

The different „Euler“ buckling mode Scoliosis: KING-classification

The buckling mode depends also on the fixation.

15y girl scoliosis since 5m after LBP (2m)

Idiopathic?

15y girl scoliosis since 5m after LBP (2m)

Disc herniation L4-5

Idiopathic?

15y girl scoliosis since 5m Partial after LBP (2m) Coalition Idiopathic? Disc herniation L5-S1 L4

Pathological orientation of the Disc herniation facet joint L4-5 WHY? Clsoed facet joint L5 Atrophie of the multifidus muscle

15y girl scoliosis since 5m Disc herniation Partial after LBP (2m) Coalition L4 L5-S1

Pathological orientation of the Clsoed L5 facet joint facet joint

Atrophie of the multifidus muscle

Ajna-24.12.01-13y

Risser 0 Menarche 0 Cobb 20° Night time bracing Family history pos Please bring your sisters to the next appointment

Elda-19.3.99-15y Denisa-3-9-00-14y Ajna-24.12.01-13y

Risser V Risser III Risser 0 Menarche >2Jahr Menarche >1Jahr Menarche 0 Cobb 22° Cobb 22° Cobb 20°

Elda-19.3.99-15y Denisa-3-9-00-14y Ajna-24.12.01-13y

Risser V Risser III Risser 0 Menarche >2Jahr Menarche >1Jahr Menarche 0 Cobb 22° Cobb 22° Cobb 20°

Elda-19.3.99-15y Denisa-3-9-00-14y Ajna-24.12.01-13y

Risser V Risser III Risser 0 Menarche >2Jahr Menarche >1Jahr Menarche 0 Cobb 22° Cobb 22° Cobb 20°

32y Rotational Gliding Back pain after bracing Osteochondritis of an idiopathic adoleszent scoliosis !

Hemisakralisation → → → → → Spondylolisthesis L4-5

B.R. 17.8.60 (05/08)

© Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 45 Idiopathic scoliosis: Yes or No Lumbosacral Spondylolysis Malformation Hemisacralisation G.M. 22.6.88 H. S. 9.10.96

repetition

Grip mechanism

Pelvic tilt Spondylolisthesis

Have an eye on the frontal side !

A.M.23.10.99

Who has to expect pain ?

•Sacral Slope

•Pelvic Tilt

•Pelvic Incidence

PI = PT + SS

•Femur Obliquity Angle FOA

•Sacral Slope

•Pelvic Tilt

•Pelvic Incidence

PI = PT + SS

•Femur Obliquity Angle FOA

Femural head

Patella alta

S.G.19.12.61

Harrington root Compensation mechanism: Hip and knee FLEXION

Pendulum Double pendulum

center of rotation

center of rotation center of rotation

In case of influences from outside

© Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 56 © Paracelsus Medizinische Privatuniversität / SOSORT-Lecture-2014-Wiesbaden / Ascending Functional Approach / F. Landauer 57 Sagittal balancing 67%: L4-S1 Lumbar Lordosis and 40%: L5/S1 movement of T5-S1 27%: L4/5

Sagittal balancing

Verlängerung

Lotaufbau

Verlängerung

Lotaufbau

Versorgung von kranial nach kaudal !

Kopffehlstellung nach WS-Fusion Orthograde Kopfeinstellung Akzeptanz aller weiteren Fehlstellungen

Kopf und Hände müssen frei sein.

Becken für die Balance.

Skoliose als Verbindung zwischen Kopf und Becken.

Füße für die Stabilität.

„Leg-length discrepancy“

Background Information: To balance the sacrum is prerequisite in the treatment of scoliosis.

Purpose: To diagnose the causes of leg-length discrepancy and their surgical treatment options