Orthopedic Surgery and the Family Hank Chambers MD

Orthopedic Surgery and the Family Hank Chambers, MD Professor of Orthopedic Surgery, University of California at San Diego Rady Children’s Hospital San Diego

What is Orthopedic Surgery? • Surgery done on the muscles, bones and joints to enable the patient to walk better, sit better and to decrease pain • Some of the indications for surgery include: – Fixed contracture – Joint dislocations – Shoe wear problems – Pain – Groin hygiene problems

What can Orthopedic Surgery Offer? • Lengthen tendons • Transfer tendons • Relocate joints • Rotate bones • Fuse joints • Cut nerves

Where does surgery fit in in the life of a person with CP?

Care of the child and adult with Cerebral Palsy • • Goal Setting Team Approach Management of Movement Disorders Therapies: Physical, Occupational, Speech Role of Technology Timing of Orthopedic Surgery Bony and Soft Tissue Surgery

First We Must Set Goals • • • Independence Working Communication Activities of Daily Living Mobility Walking

Your surgeon has recommended surgery. • Now what? • How do you know if this is the correct plan, the surgery is going to be done correctly, and whether the surgeon understands you or your child? • Tough Question!!!!! • How does one get information? – – The Internet-YIKES!!! Parent support groups Second Opinions Word of Mouth

Popular Orthopedic Surgery Approaches • Early tendon lengthening done whenever the surgeon encounters a contracture of the muscle • Delayed surgical lengthening of tendons – Open – PERC • Combination of bony surgery and tendon lengthenings or transfers at a later age: Single Event Multilevel Surgery.

Timing of Surgery Boyd, Graham et al Eur J Neur 6(supp 4), 1999

Spine Problems • Scoliosis • Spondylolisthesis

Hip Adduction Deformity • Open vs percutaneous lengthening of adductors • ? Obturator neurectomy

Hip Subluxation & Dislocation Acetabular Dysplasia Hip Subluxation

Problems at the Knee • Crouch gait • Jump gait • Stiff knee gait • Recurvatum gait

Crouch Gait • Increased hip flexion • Increased knee flexion • Increased ankle dorsiflexion (calcaneous) • Usually iatrogenic

Jump Gait • In di or hemiplegia • Increased hip flexion • Increased knee flexion • Increased ankle plantar flexion

Hamstring Lengthening

Stiff Knee Gait • Manifest by swing phase knee stiffness • Leads to problems of foot clearance • Compensatory mechanisms include – Hip Circumduction – External Rotation – Contralateral vaulting

Rotational Abnormalities • “Lever Arm Syndrome” – Increased Femoral Anteversion – Increased internal or external tibial torsion – “malignant malalignment” syndrome – Patellar subluxation/dislocation – Foot valgus

Treatment • Femoral osteotomies – Proximal – Distal • Tibial derotational osteotomies • Correction of valgus in foot

Problems at the Foot & Ankle • Equinus • Calcaneous • Varus • Valgus • Bunion

Become a partner with your surgeon • How can the family become more involved in treatment decisions and postoperative rehabilitation – Get educated on what the goal of the surgery is, what the operations that are going to be done and what the postoperative care is going to be – Ask a lot of questions – Discuss Pain Management Strategies – Ensure that the physical and occupational therapists are on the same page as the surgeon – Preorder any home health care needs such as hospital beds and lifts – Make sure that the braces are ordered before surgery – Be effective PARTNERS!

Transitions from Pediatric to Adult Care • Huge problem in the United States and the World • However, there is a possibility that there adult orthopedic surgeons who can help your adult child or yourself – All orthopedic surgeons are required to take at least 6 months of pediatric orthopedic surgery during their 5 year residency so they should have been exposed to cerebral palsy – Orthopedic surgeons are trained in caring for people who have had strokes – This is not true of medical subspecialties

Adult Clinic • 2200 Patients treated in last 15 years. • Multitude of new problems including: – – – Increased pain Arthritis Difficulty sitting Progression of movement disorder Bipolar disease (45% of all my adult patients are on antidepressants) – Loss of ambulation – Cervical Spine Problems – Progressive Hydrocephalus

What’s New in Orthopedic Surgery? • Validation of philosophies of treatment • Long term outcome studies • Comparative Effectiveness Studies on particular types of surgeries for ambulatory and nonambulatory patients. • Potential stem cell treatments to prevent contractures of the muscles from occurring.

Thank you