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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 45-48

Single event multi level orthopedic surgery in a teenager having spastic triplegic cerebral palsy


1 Faculty of Health Sciences, Sam Higginbottom Institute of Agriculture Technology and Sciences, Allahabad, Uttar Pradesh, India
2 Therapist Incharge, Samvedna, Allahabad, Uttar Pradesh, India

Date of Web Publication21-Apr-2015

Correspondence Address:
Jitender Jain
Trishla Orthopedic Clinic and Rehab Center, 182c/350a, Tagore Town, In Front of Colonelganj Inter College, Allahabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.153575

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  Abstract 

An 18-year-old boy with spastic triplegic cerebral palsy was not able to stand or walk without support (GMF Score: Level-4) and even not able to hold things with his right hand. He had undergone orthopedic surgeries previously twice in both the lower limbs and right upper limb. He also underwent static magnetic field (SMF) of median nerve for pronator and wrist flexor spasticity in right upper limb. Single Event Multilevel Orthopedic Surgeries (SEMLOS) were performed in both the lower limbs and in right upper limb with derotational osteotomy on right proximal femur and fixation with DHS. On complete reassessment 1 month after the surgery it was found that he also had lots of trouble in sensory feedback. He was given first sensory integration followed by other therapeutic exercises. Now, he is fully independent and is able to walk with elbow crutches as well as two stick support for a long distance (GMF Score- level 3). Grip as well as release of fingers in right hand have also improved.

Keywords: Cerebral palsy, osteotomy, spastic


How to cite this article:
Jain J, Jain V, Shrivastav V. Single event multi level orthopedic surgery in a teenager having spastic triplegic cerebral palsy. Indian J Cereb Palsy 2015;1:45-8

How to cite this URL:
Jain J, Jain V, Shrivastav V. Single event multi level orthopedic surgery in a teenager having spastic triplegic cerebral palsy. Indian J Cereb Palsy [serial online] 2015 [cited 2017 Mar 25];1:45-8. Available from: http://www.ijcpjournal.org/text.asp?2015/1/1/45/153575


  Introduction Top


Adolescent children with cerebral palsy develop significant contractures and deformity. [1] Their lives become more and more miserable with increasing age, but now with the latest advancements in therapeutic techniques and sophisticated surgical techniques are being proved very promising. All these children require single event multilevel surgery [2] to help them from repeated hospital admissions and mental trauma. This concept of single event multi level orthopedic surgery along with well structured therapy program gives rise to desired result in most of the properly selected patient with fixed contracture. In recent years concept of Orthopaedic selective spasticity control surgery (OSSCS) [3] has given new insight in Single Event Multilevel Orthopedic Surgeries (SEMLOS) [author would prefer this word instead of SEMLS]. By this concept balancing of muscle tone is possible by selective lengthening of multi-articular muscle and sparing of monoarticular muscles of the limbs. Second add on in SEMLOS is lever arm restoration by correction of bony torsion by derotational osteotomy. [4] It is very important to have repeated and thorough evaluation of the child beforehand for getting best result.


  Case Report Top


An 18-year-old boy with spastic triplegic cerebral palsy consulted us with the complain of not being able to stand & walk without support and very poor right hand function.

In the neonatal period itself his parents realized that his right side was not working properly, and after some time they observed that he could not grip the things properly. At the age of 1 year he was diagnosed having cerebral palsy and pediatrician advised physiotherapy. But, his parents could not follow the therapy for long time. He underwent orthopedic surgery (hamstring and gastrocnemius lengthening) in both the lower limbs at 8 years age and selective motor fasciculotomy of the right median nerve for relief of spastic pronator and wrist flexor at 14-years of age.

During his first visit at the author's center in year 2010 he was on wheel chair and could walk for a few meters with support (GMF Score: level 4). He was even not able to hold things with the right hand. On gross examination right upper limb was pronated group [4] (Gschwind Classification system), and hand function was class [3] (House Functional Classification System) with wrist extensor Grade 2a (Zancolli Classification System). Overhead abduction of shoulder was possible upto 80 degree. He could walk with very poor pelvic balance, had bilateral hallux valgus, clawing of second toe bi lateraly, limited planti-flexion of feet (5 0 ), fixed flexion deformity at hip joint (15 0 ), out toeing and hip internal rotation on right side was minus 10 0 . Quadriceps muscle power was grade 4 on both sides.

CT-scan of bilateral hip and knee revealed neck anteversion of minus 12 0 on right side (retroversion of 12 0 ) and plus 17 0 on left side [Figure 1].
Figure 1: CT-scan of bilateral hip and knee revealed neck anteversion of minus 120 on right side (retroversion of 120) and plus 170 on left side

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After detailed observational gait analysis and musculoskeletal examination preoperatively and under anesthesia We decided to perform single event multilevel soft tissue corrective surgery in both lower limbs along with de-rotational proximal femoral osteotomy on right side on first day and SEMLOS on right upper limb after three days [Figure 2].
Figure 2: X Ray Hip AP View derotational osteotomy fixed with dynamic screw

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SEMLOS was performed in both lower limbs. Surgical procedures performed were Bilateral (B/L) psoas tenotomy at pelvic brim, B/L Tibialis Anterior IML, B/L oblique Head of Adductor brevis of great toe IML, B/L flexor digitorum longus of second toe fractional lengthening, derotational osteotomy on right proximal femur with dynamic hip screw fixation.

In right upper limb surgical procedures performed were lattismus dorsi distal tenotomy, pronater teres re-routing, palmaris longus tenotomy, aponeurotic release of flexor carpi radialis, flexor digitorum profundus, flexor digitorm superficialis and flexor policis longus.

Total duration of surgery was 5 hours on first day and 3 hours on fourth day. Surgery was performed by mini incision technique. Below knee plaster on both sides and above elbow plaster on right side was applied for 2 weeks. Stitches were removed after 10 days. Joint mobilization, relaxation and s t r e n g t h e n i n g exercises were started just after removal of the plaster. Supinator splint, and bilateral articulated poly-propylene AFO were given [Figure 3] and [Figure 4].
Figure 3: Preop wheel chair user

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Figure 4: Postop walking short distances with the help of devices

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He was re-evaluated after 1 month of surgery. He was not able to extend the right knee fully. On complete reassessment it was found that he also had lots of trouble in sensory feedback (proprioception) in right lower and upper limb. Therapists were guided to focus more on sensory feedback system along with strength training exercises during first 2 months after surgery. Osteotomy segment united within 2 months of surgery. Pelvic control exercises and gait training were started after getting sufficient strength and improvement in sensory feedback problems.

He improved in walking with the help of the walker within 4 months of surgery and with elbow crutches and two sticks after 7 months of surgery. Now, in 6 months follow-up he developed walking with elbow crutches as well as two stick support for a long distance (GMF Score: level 3). Hand functions also improved appreciably (Clasp 6 by House Classification System). He is able to supinate forearm till neutral rotation (group 2 by Gschwind an Tonkin). Now he is able to manage all his activities with minimum support.


  Discussion Top


Single event multi level orthopedic surgery is a well-established procedure in the management of spastic cerebral palsy. This concept of surgery along with well-structured therapy program gives rise to desired results in most of the properly selected patients with fixed contracture. In most of the cases, only selective spasticity controls by soft tissue balancing surgery (OSSCS) suffice to give good outcome. Children and adults with severe torsional abnormality 4 of bone require derotational osteotomy 4 to correct lever arm dysfunction. Usually children with spastic cerebral palsy have increase in anteversion of femoral neck due to muscular imbalance but in our case it was retroversion [4] on right side, which is very rare in the case of cerebral palsy. It may be due to sever sensory feedback problem on right side that may have caused severe muscular imbalance in right lower extremity that would have been one of the cause of this problem.

We have observed that sensory problem may be unnoticeable with the passage of time and during therapy but whenever child becomes very ill or undergoes surgical intervention, it may reappear and interfere in therapy program and recovery.

As in our case there was no noticeable sensory problem on preoperative assessment but when reassessment was performed after 4 weeks of surgery, there was sever propioceptive feed back problem. We were able to start proper therapy only after 3 months of surgery, when sensory feedback problem was solved by sensory integration program. That's why we could not get response before 4 month post operatively otherwise in most of our cases we start getting good response within 2 months of surgery.

In our surgical technique we utilized concept of OSSCS3 which is based on the concept of spastic long multi articular [5] and short antigravity monoarticular muscle. In this technique by selective release of multiarticular muscle (intramuscular tenotomy) at all level and leaving monoarticular muscles we can balance the muscle tone in much better way. This surgical technique does not require any tendon transfer or tendon lengthening, so patient doesn't require bed rest or plaster for too long and therapy can be started within 2 weeks of surgery and child can have good recovery within 8 weeks of surgery. Till now, muscle weakening has not been observed by this concept.

Surgeries by this concept give rise to excellent result when it is performed in single stage surgical event at an in early age when child develops sufficient maturity of gait (6 year) and have already developed or start developing contracture or sever spasticity that can not be managed by therapy. Ideal age for surgical intervention is 6-9 year. [6] Surgical intervention in selected older age children also gives good recovery if they have good ability of standing with support, fully matured neck holding and good spinal balance. [7],[8],[9]

Our case had already undergone three time surgeries before coming to our centre. Single or two level surgical interventions don't help much, as children with cerebral palsy always have multi level deformity [10] and to get best result we have to manage every level of deformity in single event anesthesia setting so that the child can be saved from psychogical trauma of repeated admissions.

Result after SEMLOS is always better than single or two level surgeries. Repeated musculoskeletal examination preoperatively as well as under anesthesia, detailed gait analysis along with radiological evaluation of any torsional deformity [8] of bone is very important for correct surgical procedure. We also have to check remaining deformity after finishing one level of surgery per-operatively, so that we can have control over the under as well as over correction of the deformity. Otherwise balancing of muscle tendon length and tone will not be possible and child will have residual problem that will need another surgical intervention and also can harm the child. [7] Result after surgical intervention is based on quality of therapy program. Children, who have undergone surgery require good therapy programme [6] including strength training, pelvic balancing, functional electrical stimulation and gait training. In therapy program parents participation is also very important.

 
  References Top

1.
Ganjwala D. Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility andenergy cost. Indian J Orthop 2011;45:314-9.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Zorer G, Dogrul C, Albayrak MA. Bagatur AE. The results of single-stage multilevel muscle-tendon surgery in the lower extremities of patients with spastic cerebral palsy. Acta Orthop Traumatol Turc 2004;38:317-25.  Back to cited text no. 2
    
3.
Kondo I, Hosokawa K, Iwata M, Oda A, Nomura T, Ikeda K, et al. Effectiveness of selective muscle release surgery for children with cerebral palsy: Longitudinal and stratified analysis. Dev Med Child Neurolo 2004;46:540-7.  Back to cited text no. 3
    
4.
Inan M, Altintaº F, Duru I. The evaluation and management of rotational deformity in cerebral palsy. Acta Orthop Traumatol Turc 2009;43:106-12.  Back to cited text no. 4
    
5.
Metaxiotis D, Wolf S, Doederlein L. Conversion of biarticular to monoarticular muscles as a component of multilevel surgery in spastic diplegia. J Bone Joint Surg Br 2004;86-B:102-9.  Back to cited text no. 5
    
6.
Gough M, Schneider P, Shortland AP. The outcome of surgical intervention for early deformity in young ambulant children with bilateral spastic cerebral palsy. J Bone Joint Surg Br 2008;90:946-51.  Back to cited text no. 6
    
7.
Khan MA. Outcome of single-event multilevel surgery in untreated cerebral palsy in a developing country. J Bone Joint Surg Br 2007;89:1088-91.  Back to cited text no. 7
    
8.
Renshaw TS. Cerebral palsy: Orthopaedic management. J Bone Joint Surg Am 1995;77:1590-6.  Back to cited text no. 8
    
9.
Yalçin S, Kocaoðlu B, Berker N, Erol B. Surgical management of orthopedic problems in adult patients with cerebral palsy. Acta Orthop Traumatol Turc 2005;39:231-6.  Back to cited text no. 9
    
10.
Dobson F, Graham HK, Baker R, Morris ME. Multilevel orthopaedic surgery in group IV spastic Hemiplegia. J Bone Joint Surg Br 2005;87:548-55.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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