Parálisis Cerebral Infantil: Tratamiento ortopédico de las alteraciones de cadera y pie. Dr....

XIII INTERNATIONAL XIII INTERNATIONAL ORITEL CONFERENCEORITEL CONFERENCE

FOUNDATIONAL AND FIRST FOUNDATIONAL AND FIRST GENERAL ASSEMBLY OF THE GENERAL ASSEMBLY OF THE LATIN AMERICAN ON CHILD LATIN AMERICAN ON CHILD

DEVELOPMENT AND DISABILITYDEVELOPMENT AND DISABILITY

LA CADERA IN LA CADERA IN PARALISIS CEREBRALPARALISIS CEREBRAL

QUE HACER Y QUANDO QUE HACER Y QUANDO HACERLOHACERLO

ORTHOPEDIC CAREORTHOPEDIC CARE TEAM APPROACHTEAM APPROACH

NEURO PEDIATRIC ORTHOPEDIC NEURO PEDIATRIC ORTHOPEDIC SURGEONSURGEON

NEURO PEDIATRIC PMLRNEURO PEDIATRIC PMLR NEURO PEDIATRIC PTNEURO PEDIATRIC PT NEURO PEDIATRIC OTNEURO PEDIATRIC OT

ORTHOTISTORTHOTIST PEDIATRIC NEUROSURGEONPEDIATRIC NEUROSURGEON

Spasticity, Surgery and Spasticity, Surgery and StrengtheningStrengthening

SPASTIC CEREBRAL SPASTIC CEREBRAL PALSYPALSY

CLASSIFICATIONCLASSIFICATION

GMFC-LEVEL 1 TO 5GMFC-LEVEL 1 TO 5

FMS-LEVEL 1 TO 6FMS-LEVEL 1 TO 6

WHY?WHY?IT WILL HAVE AN INFLUENCE IN IT WILL HAVE AN INFLUENCE IN

WHAT TYPE OF SURGICAL WHAT TYPE OF SURGICAL TREATMENT THAT WE CHOOSETREATMENT THAT WE CHOOSE

CEREBRAL PALSYCEREBRAL PALSY

WHY DO THEY DEVELOP WHY DO THEY DEVELOP CONTRACTURESCONTRACTURES

BONE X MUSCLE TENDON GROWTHNORMAL CHILDBONE GROWTH RATE IS THE SAME AS THE MUSCLE/TENDON GROWTH RATE

CEREBRAL PALSYCEREBRAL PALSYSPASTICITYSPASTICITY

AFFECTAFFECTMUSCLE GROWTHMUSCLE GROWTH

RANG GRAHAMRANG GRAHAM SPASTIC MUSCLE GROWS SPASTIC MUSCLE GROWS

SLOWER(25%)SLOWER(25%)

THAN THE THE NORMAL MUSCLETHAN THE THE NORMAL MUSCLE

BONE GROWTH IS NOT AFFECT BY BONE GROWTH IS NOT AFFECT BY THE SPASTICITYTHE SPASTICITY

CEREBRAL PALSYCEREBRAL PALSYRANG STAGESRANG STAGES

STAGE ISTAGE IMUSCLE IS SPASTIC BUT HAS A MUSCLE IS SPASTIC BUT HAS A

NORMAL LENGTH NORMAL LENGTH RANGE OF MOTION IS RANGE OF MOTION IS

NORMALNORMAL IDEAL TIME TO USE BOTOXIDEAL TIME TO USE BOTOX

BRACES-AFOBRACES-AFO

CEREBRAL PALSYCEREBRAL PALSYRANG STAGESRANG STAGES

STAGE IISTAGE IITHE SPASTIC MUSCLE IS SHORTTHE SPASTIC MUSCLE IS SHORT

THERE IS A FIXED THERE IS A FIXED CONTRACTURECONTRACTURE

RANGE OF MOTION IS RANGE OF MOTION IS DECREASEDDECREASED

EXAMPLESEXAMPLES HIP ADDUCTION CONTRACTUREHIP ADDUCTION CONTRACTURE

HIP FLEXION CONTRACTUREHIP FLEXION CONTRACTURE

KNEE FLEXION CONTRACTUREKNEE FLEXION CONTRACTURE

EQUINUSEQUINUS

STAGE II

STAGE IISTAGE II MUSCLE TENDON SHORTHENINGMUSCLE TENDON SHORTHENING

SERIAL CASTING- EQUINUSSERIAL CASTING- EQUINUS

BOTOX/SPLINTING/PTBOTOX/SPLINTING/PT

INTELLIGENT STRETCHERINTELLIGENT STRETCHER

BRACES-AFOBRACES-AFO

SURGICAL LENGTHENINGSURGICAL LENGTHENING

CEREBRAL PALSYCEREBRAL PALSYRANG STAGESRANG STAGES

STAGE IIISTAGE III BONE DEFORMITIESBONE DEFORMITIES JOINT DEFORMITIESJOINT DEFORMITIES

IN ASSOCIATION WITH THE MUSCLE IN ASSOCIATION WITH THE MUSCLE CONTRACTURECONTRACTURE

SOFT TISSUE PROCEDURESSOFT TISSUE PROCEDURESBONE PROCEDURESBONE PROCEDURES

RANG STAGE IIIRANG STAGE III

SEVERE PES PLANUS VALGUS, UMBRACEABLE

DEFORMITYDEFORMITY QUESTIONSQUESTIONS

WHEN TO TREAT- TIMINGWHEN TO TREAT- TIMING

HOW TO TREAT- TECHNIQUEHOW TO TREAT- TECHNIQUE

HOW TO PREVENT HOW TO PREVENT RECURRENCERECURRENCE

HIP PATHOLOGYHIP PATHOLOGY CONTRACTURESCONTRACTURES

ADDUCTION-MOST COMMONADDUCTION-MOST COMMON FLEXIONFLEXION

SUBLUXATION SUBLUXATION DISLOCATIONDISLOCATION

ROTATIONAL DEFORMITIESROTATIONAL DEFORMITIES

ABNORMAL INTERNAL ABNORMAL INTERNAL ROTATIONROTATION

FEMORAL ANTEVERSIONFEMORAL ANTEVERSION

ABNORMAL EXTERNAL ABNORMAL EXTERNAL ROTATIONROTATION

Hip Displacement by Hip Displacement by GMFCS GMFCS Soo et al, 2006Soo et al, 2006

0102030405060708090

I I I I I I IV V

ADDUCTION ADDUCTION CONTRACTURECONTRACTURE

ABDUCTION< 45 DEGREESABDUCTION< 45 DEGREES > STRETCH REFLEX> STRETCH REFLEX

(HIP AT RISK)(HIP AT RISK)

FUNCTIONAL PROBLEMFUNCTIONAL PROBLEM SCISSORING GAITSCISSORING GAIT

THE MUSCLE IMBALANCE CAN LEAD THE MUSCLE IMBALANCE CAN LEAD TO SUBLUXATION/DISLOCATIONTO SUBLUXATION/DISLOCATION

RADIOLOGIC RADIOLOGIC EVALUATIONEVALUATION

ReimerReimer’’s s migration migration indexindex<20% <20%

Acetabular Acetabular indexindex

FLEXION CONTRACTUREFLEXION CONTRACTURE FREQUENTLY ASSOCIATED FREQUENTLY ASSOCIATED

WITH THE ADDUCTION WITH THE ADDUCTION CONTRACTURECONTRACTURE

DURING GAIT- ANTERIOR DURING GAIT- ANTERIOR PELVIC TILT AND INCREASE PELVIC TILT AND INCREASE

LUMBAR LORDOSISLUMBAR LORDOSIS

TIMINGTIMING EARLY SURGERYEARLY SURGERY

< 4 YEARS OF AGE< 4 YEARS OF AGE MIGRATION INDEX < 30 %MIGRATION INDEX < 30 %

PASSIVE HIP ABDUCTIONPASSIVE HIP ABDUCTION IN FLEXIONIN FLEXION

< 45 DEGREES< 45 DEGREES

BILATERALBILATERAL

FLEXION/ADDUCTION FLEXION/ADDUCTION CONTRACTURECONTRACTURE

SURGICAL TREATMENTSURGICAL TREATMENT

ADDUCTOR MYOTOMYADDUCTOR MYOTOMYTransverse incision, aim to 60 degrees Transverse incision, aim to 60 degrees

of passive abductionof passive abductionLongus/part of brevis/gracilisLongus/part of brevis/gracilis

IP LENGTHENING IP LENGTHENING Above the brimAbove the brim

POST OPPOST OP HIP SPLINTHIP SPLINT

TBSTBSABDUCTION WEDGEABDUCTION WEDGE

FULLTIME – 12 DAYSFULLTIME – 12 DAYSNIGHT TIMENIGHT TIME

HIP SPLINT

FINAL GOALFINAL GOAL IMPROVE MOBILITY/ IMPROVE MOBILITY/

AMBULATIONAMBULATION

PREVENT HIP SUBLUXATION PREVENT HIP SUBLUXATION DISLOCATIONDISLOCATION

3 YEARS OLDR/L ADD/IP L>R

6 MONTHS POST OP

2 YEARS POST OP

SURVIVORSHIP ANALYSIS OF ADDUCTOR SURVIVORSHIP ANALYSIS OF ADDUCTOR SURGERY TO PREVENT HIP SURGERY TO PREVENT HIP

DISPLACEMENT IN CHILDREN WITH DISPLACEMENT IN CHILDREN WITH CEREBRAL PALSYCEREBRAL PALSY POSNA 2009POSNA 2009

BENJAMIN SHOREBENJAMIN SHORE PAULO SELBERPAULO SELBER KERR GRAHAMKERR GRAHAM

ROYAL CHILDRENROYAL CHILDREN’’S HOSPITALS HOSPITALAUSTRALIAAUSTRALIA

RESULTRESULT

SUCCESS- NO FURTHER SXSUCCESS- NO FURTHER SX GMFC II-94%GMFC II-94% GMFC III-49%GMFC III-49% GMFC-IV-27%GMFC-IV-27% GMFC V-14%GMFC V-14%

RIC/LCHRIC/LCH EARLY SURGERYEARLY SURGERY

RIEMER <30%RIEMER <30%

50% DID NOT REQUIRED 50% DID NOT REQUIRED FURTHER SURGERYFURTHER SURGERY

CONCLUSIONSCONCLUSIONS GMFC LEVEL IS THE PRIMARY GMFC LEVEL IS THE PRIMARY

PREDICTOR OF SUCCESSPREDICTOR OF SUCCESS

PRE OP MP SECONDARY PRE OP MP SECONDARY PREDICTORPREDICTOR

IMPORTANTIMPORTANT PHYSICAL THERAPY, SPLINTINGPHYSICAL THERAPY, SPLINTING WILL NOT PREVENT HIPWILL NOT PREVENT HIP DISLOCATIONDISLOCATION SHARRARD STUDYSHARRARD STUDY

LEVER ARM DYSFUNCTIONLEVER ARM DYSFUNCTION

HIPHIP

SUBLUXATIONSUBLUXATION COXA VALGACOXA VALGA

FEMORAL ANTEVERSIONFEMORAL ANTEVERSION (lever arm dysfunction)(lever arm dysfunction)

DO FEMURDO FEMUR PROXIMALPROXIMAL

AO PLATE FIXATIONAO PLATE FIXATION 6 HOLE PLATE6 HOLE PLATE

TBSTBS EARLY MOTIONEARLY MOTION

IN PATIENT PT AT 6 WEEKSIN PATIENT PT AT 6 WEEKS

DO FEMURDO FEMUR

TIMINGTIMING WAIT UNTIL CHILD REACH A WAIT UNTIL CHILD REACH A

STABLE GAIT PATTERNSTABLE GAIT PATTERN

BEST AGE – BETWEEN 6 TO 8BEST AGE – BETWEEN 6 TO 8

GAIT ANALYSIS/3DGAIT ANALYSIS/3D

HIP SUBLUXATION

ACETABULAR DYSPLASIARANG III

HIP DISLOCATIONHIP DISLOCATION PAIN CAN BE A MAJOR PAIN CAN BE A MAJOR

PROBLEMPROBLEM THE QUESTION IS WHEN, AT THE QUESTION IS WHEN, AT

WHAT AGEWHAT AGE MOST OF THE TIME OLDER MOST OF THE TIME OLDER CHILD, OVER THE AGE OF 10CHILD, OVER THE AGE OF 10

PATIENT SELECTIONPATIENT SELECTION GMFC LEVELGMFC LEVEL

OTHER MEDICAL PROBLEMSOTHER MEDICAL PROBLEMS

DEGREE OF ACETABULAR DEGREE OF ACETABULAR DYSPLASIADYSPLASIA

SHAPE OF THE FEMORAL HEADSHAPE OF THE FEMORAL HEAD

PRE OP EVALUATIONPRE OP EVALUATION PELVIS XRAYPELVIS XRAY

CT 3D PELVISCT 3D PELVIS

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

ROTATIONAL PROFILEROTATIONAL PROFILE

HIP DISLOCATIONHIP DISLOCATION IF ACETABULAR DYSPLASIA IS NOT IF ACETABULAR DYSPLASIA IS NOT

TOO SEVERETOO SEVERE

IF FEMORAL HEAD STILL HAVE A IF FEMORAL HEAD STILL HAVE A ROUND SHAPEROUND SHAPE

PROCEDURE-BILATERAL VDO/SAN PROCEDURE-BILATERAL VDO/SAN DIEGO/DEGADIEGO/DEGA

IN COMPLETE DISLOCATION ALSO IN COMPLETE DISLOCATION ALSO OPEN REDUCTIONOPEN REDUCTION Rarely neededRarely needed

PATIENT SELECTIONPATIENT SELECTION GMFC 1/2/3/4/5GMFC 1/2/3/4/5

VDO/DEGAVDO/DEGA

GMFC 4/5GMFC 4/5 SALVAGE PROCEDURESSALVAGE PROCEDURES

SHANZ VALGUS OSTEOTOMYSHANZ VALGUS OSTEOTOMYMCHALE/SHANZMCHALE/SHANZ

PROXIMAL FEMORAL RESECTIONPROXIMAL FEMORAL RESECTION

HIP SUBLUXATIONHIP SUBLUXATIONDISLOCATIONDISLOCATION

ADDUCTOR MYOTOMYADDUCTOR MYOTOMY

IP LENGTHENINGIP LENGTHENING VDO/FEMORAL SHORTHENINGVDO/FEMORAL SHORTHENING

PELVIC OSTEOTOMY/ DEGA/SAN PELVIC OSTEOTOMY/ DEGA/SAN DIEGODIEGO

VDO ALWAYS BILATERALVDO ALWAYS BILATERAL OPEN REDUCTION ONLY WHEN OPEN REDUCTION ONLY WHEN

CAPSULAR LAXITY(rare)CAPSULAR LAXITY(rare)

ACETABULARDYSPLASIA

VALGUSANTEVERSION

DEGA

A.H. – POST-OPA.H. – POST-OP

E.T.E.T.

1 y post-op1 y post-op

Pre-op

POST-POST-OPERATIVE OPERATIVE

MANAGEMENTMANAGEMENT Total body splint vs.

spica cast With TBS: early active/

passive ROM

Supported standing may begin when evidence of healing ~3-4 weeks

Walking with supervision beginning at 6 weeks

Inpatient rehabilitation admission at 6 weeks

OUR RESULTSOUR RESULTS 70 patients in past 4 years70 patients in past 4 years

7 required open reduction7 required open reduction

No redislocationsNo redislocations 3 required further surgery:3 required further surgery:

1 over derotation1 over derotation Required revision DO femurRequired revision DO femur

2 (both done at 4y of age) remodeled varus 2 (both done at 4y of age) remodeled varus correction on non-SD sidecorrection on non-SD side

Need revision VDRO/ SDNeed revision VDRO/ SD

HIP SUBLUXATIONHIP SUBLUXATIONNO ACETABULAR DYSPLASIANO ACETABULAR DYSPLASIA

BILATERAL VDOBILATERAL VDO

FEMORAL SHORTHERNINGFEMORAL SHORTHERNING

BILATERAL ADDUCTOR BILATERAL ADDUCTOR MYOTOMYMYOTOMY

HIPHIPSALVAGE SALVAGE

PROCEDURESPROCEDURES

SALVAGE SURGERYSALVAGE SURGERY

Hip dislocation may lead Hip dislocation may lead to pain, functional to pain, functional impairment affecting the impairment affecting the ability to sit, stand, and ability to sit, stand, and walk, as well as an walk, as well as an impaired quality of lifeimpaired quality of life

20% to 80%-pain20% to 80%-pain

Robin J et al. (Dev Med Child Neurol 2009)

HIP DISLOCATIONHIP DISLOCATION SEVERE ACETABULAR SEVERE ACETABULAR

DYSPLASIADYSPLASIA

DEFORMED FEMORAL HEADDEFORMED FEMORAL HEAD

RANG STAGE IIIRANG STAGE III

Indications= Indications=

Options:Options: Femoral head resectionFemoral head resection Proximal femur Proximal femur

resectionresection Schanz osteotomySchanz osteotomy McHale osteotomyMcHale osteotomy Hip arthrodesisHip arthrodesis Replacement Replacement

arthroplastyarthroplasty

SALVAGE SURGERYSALVAGE SURGERY McHale osteotomy McHale osteotomy

= = Femoral head Femoral head

resection + resection + proximal femur proximal femur valgus osteotomyvalgus osteotomy

Relieves painRelieves pain Eases perineal Eases perineal

carecare Facilitates sittingFacilitates sitting

McHale et al (J Pediatr Orthop 1990)

McHALE PROCEDUREMcHALE PROCEDURE McHALE 1999McHALE 1999

5 HIPS5 HIPS JOHN HOPKINSJOHN HOPKINS

11 HIPS11 HIPS

McHALE PROCEDUREMcHALE PROCEDURE FEMORAL HEAD RESECTIONFEMORAL HEAD RESECTION

SUBTHROCANTERIC VALGUS SUBTHROCANTERIC VALGUS OSTEOTOMYOSTEOTOMY

ADDUCTOR MYOTOMYADDUCTOR MYOTOMY

HIP DISLOCATIONHIP DISLOCATION SHANZ VALGUS OSTEOTOMYSHANZ VALGUS OSTEOTOMY

McHALE PROCEDUREMcHALE PROCEDURE

CASTLE PROCEDURECASTLE PROCEDURE

POST OPPOST OP TOTAL BODY SPLINT- FULL TIME TOTAL BODY SPLINT- FULL TIME

FOR 2 WEEKSFOR 2 WEEKS

AFTER-ONLY AT NIGHTAFTER-ONLY AT NIGHT

START GENTLE PASSIVE ROM START GENTLE PASSIVE ROM AND ACTIVE ROMAND ACTIVE ROM

In patient rehab at 6 weeks post opIn patient rehab at 6 weeks post op

SALVAGE SALVAGE SURGERYSURGERY

McHale osteotomy = McHale osteotomy = Femoral head resection + proximal femur Femoral head resection + proximal femur

valgus osteotomyvalgus osteotomy

Our experience:Our experience: 17 patients in past 4 years17 patients in past 4 years 1 patient with residual pain1 patient with residual pain No incidence of proximal migration, heterotopic No incidence of proximal migration, heterotopic

ossification, or recurrence of contractureossification, or recurrence of contracture Study ongoingStudy ongoing

SHANZ VALGUS SHANZ VALGUS OSTEOTOMYOSTEOTOMY

45 DEGREES VALGUS45 DEGREES VALGUS

ADDUCTOR MYOTOMYADDUCTOR MYOTOMY

FEMORAL HEAD PROTUSIONFEMORAL HEAD PROTUSION

CMH EXPERIENCECMH EXPERIENCE

WINDBLOWN HIPR VALGUS EXTERNAL DEROTATION OSTEOTOMYL VARUS INTERNAL DEROTATION OSTEOTOMY

SHANZ PROCEDURE

PROXIMAL FEMORAL PROXIMAL FEMORAL RESECTIONRESECTION

CASTLE PROCEDURECASTLE PROCEDURE

NEED POST OP TRACTIONNEED POST OP TRACTION

ECTOPIC BONE FORMATIONECTOPIC BONE FORMATION

ONLY 2 CASESONLY 2 CASES

R VALGUS OSTEOTOMYL PROXIMAL FEMORAL RESECTION

AACDAACD COMPARISONCOMPARISON

McHALE X CASTLEMcHALE X CASTLE

SAME AS FAR PAIN RELIEFSAME AS FAR PAIN RELIEF

McHALE EASIER POST OPMcHALE EASIER POST OP

SUMMARYSUMMARY

Goal of hip management in Goal of hip management in cerebral palsy = careful cerebral palsy = careful screening and early treatmentscreening and early treatment

Measure hip abductionMeasure hip abduction Follow pelvis radiographsFollow pelvis radiographs Soft-tissue lengthening earlySoft-tissue lengthening early Comprehensive bony Comprehensive bony

reconstruction when indicatedreconstruction when indicated Avoid need for salvage proceduresAvoid need for salvage procedures

WARNINGWARNING HIP HIP

SUBLUXATION/DISLOCATION SUBLUXATION/DISLOCATION CAN ALSO BE SEEN IN CAN ALSO BE SEEN IN

DYSTONIC PATIENTS AS WELL DYSTONIC PATIENTS AS WELL HYPOTONIC PATIENTSHYPOTONIC PATIENTS

BE AWAREBE AWARE IF EVEN ROM IS NORMAL TAKE IF EVEN ROM IS NORMAL TAKE

PELVIS XRAYS ONCE A YEARPELVIS XRAYS ONCE A YEAR

ANKLE/FOOT DEFORMITIESANKLE/FOOT DEFORMITIES EQUINUSEQUINUS

EQUINOVARUS-hemiplegiaEQUINOVARUS-hemiplegia EQUINOVALGUS-diplegiaEQUINOVALGUS-diplegia

HINDFOOT VALGUSHINDFOOT VALGUS HINDFOOT VALGUS/FOREFOOT HINDFOOT VALGUS/FOREFOOT

ABDUCTIONABDUCTION VARUS, HINDFOOTVARUS, HINDFOOT

SUPINATION FOREFOOTSUPINATION FOREFOOT

40-50%

20-30%

POWER GENERATIONMUSCLES

20-30%

EQUINUSEQUINUS<6 Y.O<6 Y.O..

SERIAL CASTINGSERIAL CASTING BOTOXBOTOX

Avoid Avoid SOLEUSSOLEUS surgery surgery WELL KNOWN TO CAUSE WELL KNOWN TO CAUSE

WEAKNESSWEAKNESS

ANKLEANKLE GASTROCNEMIUS RECESSION-GASTROCNEMIUS RECESSION-

zone 1zone 1 GASTROSOLEUS RECESSION-GASTROSOLEUS RECESSION-

zone 2 zone 2 Z TAL (severe equinus-zone 3)Z TAL (severe equinus-zone 3)

POST TIB LENGTHENINGPOST TIB LENGTHENING PERONEUS BREVIS PERONEUS BREVIS

LENGTHENINGLENGTHENING

Triceps Surae Anatomy: Triceps Surae Anatomy: Zones 1-3Zones 1-3

Zone 1

Zone 1

MILDEQUINUS

GASTROCNEMIUS RECESSION

POST OPPOST OPZONE 1 OR 2ZONE 1 OR 2

CALF LENGTHENINGCALF LENGTHENING SHORT LEG CASTSHORT LEG CAST

12 DAYS12 DAYS CAN START WB DAY AFTER CAN START WB DAY AFTER

SURGERYSURGERY NEW AFO BRACE MEASURED NEW AFO BRACE MEASURED

IN THE ORIN THE OR

EQUINOVALGUSEQUINOVALGUSDIPLEGIADIPLEGIA FLEXIBLEFLEXIBLE

GOOD SUBTALAR JOINT GOOD SUBTALAR JOINT MOBILITYMOBILITY

ZONE 1 OR 2 CALFZONE 1 OR 2 CALF

PERONEUS BREVIS PERONEUS BREVIS LENGTHENINGLENGTHENING

EQUINO VARUSEQUINO VARUSHEMIPLEGIAHEMIPLEGIA

FLEXIBLE SUBTALAR JOINTFLEXIBLE SUBTALAR JOINT

ZONE 1 OR 2 CALF ZONE 1 OR 2 CALF LENGTHENINGLENGTHENING

INTRAMUSCULAR POSTERIOR INTRAMUSCULAR POSTERIOR TIB LENGTHENINGTIB LENGTHENING

EQUINOVARUSEQUINOVARUSSUPINATION DEFORMITYSUPINATION DEFORMITY ZONE 2 CALF LENGTHENINGZONE 2 CALF LENGTHENING

INTRAMUSCULAR POSTERIOR INTRAMUSCULAR POSTERIOR TIB LENGTHENINGTIB LENGTHENING

SPLATTSPLATT

HEMIPLEGIAHEMIPLEGIA

ANTERIORTIBIAL

EQUINOVARUS EQUINOVARUS DEFORMITYDEFORMITY RIGID VARUSRIGID VARUS

ZONE 2 CALF LENGTHENINGZONE 2 CALF LENGTHENING

POSTERIOR TIB LENGTHENINGPOSTERIOR TIB LENGTHENING

DWYER CALCANEUS DWYER CALCANEUS OSTEOTOMYOSTEOTOMY

SEVERE PES PLANUS VALGUS, UMBRACEABLE

PES PLANUS VALGUSPES PLANUS VALGUS PROBLEMSPROBLEMS

BRACESBRACES PRESSURE SORE TALAR HEADPRESSURE SORE TALAR HEAD

PAINPAIN CROUCH GAITCROUCH GAIT

LEVER ARM DYSFUNCTIONLEVER ARM DYSFUNCTION

3C: Calcaneal-3C: Calcaneal-Cuboid-Cuneiform Cuboid-Cuneiform Osteotomies for Osteotomies for

Valgus Foot Valgus Foot DeformitiesDeformities Rathjen & Mubarak..Rathjen & Mubarak..

J. Ped. Ortho 18:775,1998

TRIPLE TRIPLE ““CC ”” MEDIAL SLIDING OSTEOTOMY MEDIAL SLIDING OSTEOTOMY

OS CALCISOS CALCIS OPENING WEDGE OSTEOTOMY OPENING WEDGE OSTEOTOMY

CUBOIDCUBOID PLANTAR WEDGE OSTEOTOMY PLANTAR WEDGE OSTEOTOMY

MEDIAL CUNEIFORMMEDIAL CUNEIFORM (MUBARAK)(MUBARAK)

TRIPLE CTRIPLE C FREQUENTLY ASSOCIATED FREQUENTLY ASSOCIATED

WITHWITH

1- CALF LENGTHENING1- CALF LENGTHENING

2-PERONEUS BREVIS 2-PERONEUS BREVIS LENGTHENINGLENGTHENING

FOOT PRESSURE FOOT PRESSURE ANALYSISANALYSIS

RECENT STUDY AT MACRECENT STUDY AT MAC

10 FEET10 FEET IMPROVEMENT IN THE WEIGHT IMPROVEMENT IN THE WEIGHT

DISTRIBUTIONDISTRIBUTION IMPROVEMENT WEIGHT IMPROVEMENT WEIGHT

PROGRESSIONPROGRESSION

PRE OP

TRIPLE C LEFT

SOME SOME RESULTSRESULTS

JTJT R/L TRIPLE CR/L TRIPLE C

R/L ZONE 1 CALF R/L ZONE 1 CALF LENGTHENINGLENGTHENING

R/L PERONEUS BREVIS LENGTHR/L PERONEUS BREVIS LENGTH R/L MED/LAT HAMSR/L MED/LAT HAMS

R/L DO TIBIAR/L DO TIBIA

MANAGEMENT OF MANAGEMENT OF SPASTICITYSPASTICITY

ANDANDMOTOR MOTOR

DYSFUNCTIONDYSFUNCTIONSURGICAL PLANNINGSURGICAL PLANNING

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

RIC 2007RIC 2007

3 C3 CLAST 7 YEARSLAST 7 YEARS

72 FEET72 FEET

Valgus DeformityValgus Deformity

MOTIONMOTIONIS IS

LIFELIFENO ARTHRODESISNO ARTHRODESISPERI ARTICULAR PERI ARTICULAR OSTEOTOMIESOSTEOTOMIES

Thank you!