PowerPoint Presentation - AACPDM · 9/14/2015 3 most common deformities hip flexion contractures knee flexion contractures equinus adult problems lower extremity edema

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DISCLOSURE INFORMATION AACPDM 69TH ANNUAL MEETING | OCTOBER 21-24, 2015

Speaker Name: Luciano Dias, MD; Vineeta T. Swaroop, MD; Rachel M. Thompson, MD

Disclosure of Relevant Financial Relationships

I have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative uses:

I will not discuss off label use and/or investigational use in my presentation

CONTROVERSIES IN ORTHOPAEDIC

MANAGEMENT OF PATIENTS WITH

MYELOMENINGOCELE

Introduction Luciano Dias, MD

SURVIVAL RATE

1950-10%

PRESENTLY 75% CAN EXPECT TO REACH EARLY

ADULT YEARS

HIGHEST MORTALITY – FIRST YEAR OF LIFE

INCIDENCE

FROM 1983 TO 1990-4.6 PER 10.000

GRADUAL DECREASE

2 MAIN FACTORS

1. ABORTION

2. FOLIC ACID

INCIDENCE

AFTER FOLIC ACID MANDATE

1.9 PER 10.000 LIVE BIRTH

FMS

FUNCTIONAL MOBILITY SCALE

FMS

ABILITY TO WALK 3 SPECIFIC DISTANCES

5 / 50 / 500 meters

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(FMS)

Graham HK, Harvey A. et al. The Functional Mobility

Scale (FMS). J Pediatr Orth 2004

6

6

6

1

1

1

3

3

1

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2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

ORTHOPEDIC CARE

START AT BIRTH

PHYSICAL EXAMINATION

MANUAL MUSCLE TEST

SPINE/PELVIS XRAYS

FUNCTIONAL

MOTOR LEVEL

High Lumbar/ Thoracic

Low Lumbar

High sacral

Low sacral

HIGH LEVEL

No Quadriceps

MAY HAVE HIP FLEXORS

RGO/HKAFO

PARAPODIUM if seating balance is poor

FMS 2/2/1when < age of 10

Most will stop walking by

11 to 13 years of age

Obesity is common

Adult-99% wheel chair mobility (FMS 1/1/1)

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HIGH

LEVEL FMS 3/3/1

FMS 2/1/1

FMS 2/2/1

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MOST COMMON DEFORMITIES

HIP FLEXION CONTRACTURES

KNEE FLEXION CONTRACTURES

EQUINUS

ADULT PROBLEMS

LOWER EXTREMITY EDEMA

PRESSURE SORES ISCHIUM

LOW LUMBAR LEVEL

HIP FLEXORS- STRONG

KNEE EXTENSOR- STRONG

MEDIAL HAMS- STRONG

GLUTEUS MEDIUS- 2 OR LESS

GLUTEUS MAXIMUS- 2 OR LESS

GASTROSOLEUS- 0

LOW LUMBAR

Walk with AFO and Crutches at an average walking velocity 60 % of expected

YOUNG- FMS 3/3/3

80% retain walking ability as adult

FMS 3/3/1

WHEN OBESE

FMS 3/1/1

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LOW LUMBAR

FMS 3/3/3 9/2/11


LOW LUMBAR

FMS 3/3/1

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LOW LUMBAR

UNCOMMON

NO SHUNT

FMS 5/5/3

MOST COMMON PROBLEMS

KNEE FLEXION CONTRACTURE

CROUCH GAIT

EXTERNAL TIBIA TORSION

VALGUS KNEE STRESS


ANKLE VALGUS

HINDFOOT VALGUS

HIP CONTRACTURES

HIP DISLOCATION DOES NOT AFFECT THEIR WALKING ABILITY

ADULT PROBLEMS

SWELING LOWER EXTREMITY

PRESSURE SORE ANKLE/FOOT

OBESITY CAN AFFECT THEIR MOBILITY

HIGH SACRAL

Weak Gluteus Medius and Maximus (2 or>)

Gastrosoleus strength < 3

AFO(solid)

Gluteus Lurch

FMS 5/5/5 or 5/5/3 or 6/6/6

Walking velocity 75%

94% retain walking ability as adult

HIGH SACRAL; WITH AFO

FMS 5/5/5

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CROUCH GAIT


EXTERNAL TIBIAL TORSION

ROTATIONAL DEFORMITIES FEMUR

HIP SUBLUXATION


HIND FOOT VALGUS

HINDFOOT VARUS

CAVOVARUS FOOT

LOW SACRAL LEVEL

LOW SACRAL

Less than 5%

Strong gluteus medius and maximus >3

Strong gastrosoleus 3 or >

Do not need AFO

May need SMO

No gluteus lurch

Normal gait

FMS 6/6/6

FUNCTIONAL COMPARISON BETWEEN SHUNT

AND NO SHUNT PATIENTS WITH

MYELOMENINGOCELE

BATTIBUGLI

Gait Analysis

Parameters Linear Parameters

Velocity Cadence Stride Length

NO SHUNT 94.4 93 103

SHUNT 76.4 86 88.4

Group 3

Group 4

P- 0.0009 VELOCITY P- 0.003 STRIDE LENGTH



MYELOMENINGOCELE

FMS 6 6 6

SACRAL LEVEL

Group 1 - No Shunt 71.4%

Group 2 - Shunt 54.9%

FMS


500

HAVING NO SHUNT WAS SIGNIFICANTLY ASSOCIATED WITH

HIGHER

FMS 500

P- 0.01

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MYELOMENINGOCELE

Conclusion

The functional mobility of no shunt patients, was found to be better in our MM study population in relation of the linear gait parameters and Functional Mobility Scale – FMS

Neurosurgeons should be aware of these differences and develop strict guidelines to when insert a shunt

THE NUMBER OF SHUNT REVISIONS DOES NOT

AFFECT THE WALKING SPEED AND FMS

SHUNT INFECTION HAS A MAJOR EFFECT ON

MOBILITY/ SPEED AND FMS

HYDROCEPHALUS

1985

A REVIEW OF 200 CHILDREN CLOSED AT CMH

92% SHUNT

2010

65%

“THE BEST SHUNT IS NO SHUNT”



MYELOMENINGOCELE

Hip subluxation/ dislocation Vineeta T. Swaroop, MD

Affects up to 50% spina

bifida patients

Common but complicated

problem

Treatment remains

controversial

HIP INSTABILITY

1960s and 1970s

◦ Aggressive treatment approach for ALL patients

◦ Transfer of iliopsoas tendon

◦ External oblique transfer/ varus osteotomy

◦ Goal = anatomic reduction of hip

“Successful” result based on anatomic/ radiographic results

Little regard for functional consequences

Concern: did hip reduction lead to ↓ ROM,

complications???

HIP INSTABILITY

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Attempted surgical reduction: ◦ Multiple studies high complication rate

◦ Worsened neuological deficit, loss of motion, pathologic fractures

Sherk DMCN 1991: ◦ Compared op to non-op treatment

◦ Surgical group: 36% ↓ ambulatory capacity

Bazih JPO 1981: ◦ 74 patients with surgical treatment

◦ 45% had redislocation

◦ Conclusion: surgery had no benefit for ambulation

HIP INSTABILITY MORE POOR OUTCOMES

After attempted surgical reduction:

Sherk and Ames Clin Orthop 1978

• 53% redislocation rate

• 11% worsening neurological deficit

• Pathologic fractures common

Feiwell JBJS 1978

• 29% loss of motion

• 17% pathologic fractures

1978: Feiwell

Compared functional results:

◦ 35 – surgical hip reduction

◦ 41 – no operative treatment

Surgical group: 40% redislocation rate

◦ No improvement in ROM, ambulation

◦ No ↓ pain ↓ or need for bracing

Gait function depends on level pelvis and adequate

ROM rather than anatomic joint reduction!

HIP DISPLACEMENT

Radical change in goals of treatment:

Previously, goal = anatomic location of hip joint

• Iliopsoas transfer, external oblique transfer, VDRO

• Many studies have shown poor functional outcomes

Now, goal = maximum function, emphasis on gait

• ‘A level pelvis and a good range of hip motion are more

important for function than reduction of the hips. The goal of

treatment should be maximum function, not radiographic

reduction of the dislocated hips’ Feiwell 1978

Current treatment:

• Focuses on maximal functional results

• NOT radiographic reduction

Gait analysis data supports this approach

Treatment:

• Based on patient’s functional level of involvement

• Focus on maintaining hip range of motion

HIP INSTABILITY HIP INSTABILITY

General consensus in literature: Ambulatory ability does

not depend on status of the hip but rather

most important factor is level of functional

involvement

Preserving muscle strength of iliopsoas and quadriceps

is more relevant than status of hip joint in terms of

potential for continued ambulation in adulthood

Barden JBJS, Sherk CORR, Feiwell JBJS, Sherk DMCN, Feiwell CORR

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HIP SUBLUXATION /DISLOCATION:

THORACIC AND HIGH-LUMBAR LEVELS

Stability of hip joint has little clinical effect on

function

Treatment limited to contracture release to

allow: • Proper sitting posture

• Perineal care

• Facilitate use of orthoses for ambulation, if appropriate

NO CONVINCING EVIDENCE TO SUPPORT HIP

REDUCTION IN THIS GROUP

LOW LUMBAR: high incidence of hip instability Underlying muscle imbalance

Debate remains over correlation between hip instability and impaired ambulatory ability • Multiple studies failed to demonstrate relationship btw hip status

and ambulatory ability

Some authors have advocated reduction of unilateral cases to improve ambulation and avoid possible LLD, pelvic obliquity, and scoliosis • No studies use objective measures (3D GA)

• Benefits not clearly substantiated

• Incidence of complications is high


LOW-LUMBAR AND SACRAL LEVELS

LOW-LUMBAR LEVEL:

UNILATERAL DISLOCATION

Indications for hip reduction?

3D Gait analysis study:

• Examined influence of unilateral hip

dislocation on gait

• 20 patients (low-lumbar)

• Community ambulators with solid AFOs

+ crutches

Gabrieli et al J Pediatr Orthop 2003

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LOW-LUMBAR LEVEL:


GROUP I:

◦ 10 patients

◦ No contracture or

symmetric contracture

GROUP II

◦ 10 patients

◦ Unilateral hip flexion

and/or adduction

contracture

Pelvic and hip kinematics assessed to determine

symmetry of motion between involved and non-involved

side during ambulation:

-Pelvic obliquity, pelvic tilt, pelvic rotation, hip rotation,

hip ab/adduction, hip flexion/ extension

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GAIT PARAMETERS

GROUP I:

◦ No contracture or

symmetric contracture

◦ 70% patients – symmetric

gait pattern (<10°

difference btw unstable hip

and contralateral side)

GROUP II

◦ Unilateral contracture

◦ 20% patients – symmetric

gait pattern

No difference in stride length, cadence,

walking velocity or LLD between groups

GROUP I: CHARACTERISTIC PATIENT

0 10 20 30 40 50 60 70 80 90 100

% Gait Cycle

0

10

20

30

-10

-20

-30

Pelvic Obliquity

Subluxed Side in Red

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GROUP I: CHARACTERISTIC PATIENT

0 10 20 30 40 50 60 70 80 90 100

% Gait Cycle

0

10

20

30

-10

-20

-30

Subluxed Side in Red

Hip Abduction/Adduction L adduction contracture

GROUP II: CHARACTERISTIC PATIENT

Left

Right

Normal

L adduction contracture

GROUP II: CHARACTERISTIC PATIENT

Left

Right

Normal

GAIT PARAMETERS-


In both groups, walking speed = 60% of normal

• Corresponds to velocity of low-lumbar patients without hip

dislocations

Hence, unilateral hip instability does not influence

walking velocity

LOW-LUMBAR LEVEL:


Conclusions:

Gait symmetry corresponds to absence of hip

contractures or bilateral symmetrical hip contractures

NO RELATION to presence of hip dislocation

Reduction of hip is unnecessary!

LOW-LUMBAR LEVEL:


Conclusions:

Challenges efficacy of surgery to relocate hip

• Since hip instability in these patients has minimal effect on

gait symmetry

If contractures are causing gait asymmetry

Address contractures surgically (Treat the

FUNCTIONAL deformity)

Gait symmetry will likely be restored

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Relatively rare BUT challenging treatment dilemma

In contrast to low-lumbar patients who walk with crutches….

In sacral level patient who walks with no support:

Hip instability can lead to lever arm dysfunction • ↑ Trunk – pelvic lurch due to loss of fulcrum

• ↑ Pelvic obliquity

• ↑ Gait asymmetry

Functional abductor strength can be compromised

Should sacral level patients be considered for surgical relocation???


SACRAL LEVEL

Factors to consider:

Prospect for independent ambulation thru adulthood?

Magnitude of asymmetry during gait?

Joint integrity?

Careful consideration for surgical reduction in this group to

maintain independent ambulation as adult

Further studies necessary to assess results of surgical

treatment


SACRAL LEVEL

HIP DISPLACEMENT – SACRAL LEVEL

Muscle weakness – gluteus

Tethered cord

We are finding more and more subluxated hips in these patients • 6 patients in past 36 months

• Looking at series with pre- and post-op GA

Need for screening AP pelvis in sacral level patients?

SACRAL LEVEL

UNILATERAL HIP SUBLUXATION Treat all cases???

One stage hip reconstruction: ◦ Adductor myotomy

◦ Varus derotational osteotomy of proximal femur

Bilateral?

◦ Open reduction/ capsulotomy

◦ Acetabuloplasty

Soft-tissue lengthening

Varus derotational osteotomy of proximal

femur

• Closing wedge osteotomy

• Blade plate for fixation

• Femur shortening if needed

• Derotation if needed

• Goal = Neck shaft angle 110-120°,

anteversion 10-20°

Capsulotomy

Acetabuloplasty

ONE-STAGE HIP RECONSTRUCTION

CONCLUSION

Available literature supports LEVEL OF NEURAL

DEFICIT as most important predictor of ambulatory ability

Most authors agree: extensive surgery to reduce hip

dislocations is not indicated

Treatment goals = level pelvis, free motion of the hips

Recommended surgical treatment = contracture release

when necessary

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TO REDUCE OR NOT TO REDUCE THE HIP –

CURRENT RECOMMENDATIONS

Thoracic/ High-lumbar/ Low-lumbar level

• If contracture exists, causing asymmetrical gait:

Treatment with soft tissue release indicated to improve gait

No attempt should be made to reduce hip joint

Sacral level

• If dislocation present in a child who walks with no support:

Consider possibility of tethered cord

Surgical relocation indicated to correct lever arm dysfunction

Soft tissue release, open reduction, VDRO, pelvic osteotomy

Muscle imbalance ◦ E.g. low-lumbar level: lacks normal strength in

gluteals relatively greater strength in hip flexors/ adductors leads to hip deformity

◦ Type/ severity of contracture depends on degree of muscle imbalance present

Positioning ◦ Especially in high levels of involvement – rely

on wheelchair for mobility

Spasticity ◦ Tethered cord syndrome

HIP CONTRACTURES: ETIOLOGY

Can affect function more than

subluxation/ dislocation

Untreated

◦ Pelvic obliquity

◦ Compensatory spinal deformity

Gait analysis:

◦ Unilateral hip flexion/ adduction

contracture

◦ ↑ pelvic obliquity

◦ Asymmetric gait/ compensatory

scoliosis

HIP CONTRACTURES

Gabrieli et al J Pediatr Orthop 2003

Symmetric gait pattern:

• Absence of hip contracture or

• Bilateral symmetric hip contractures

• No relation to hip dislocation

Current treatment goals:

• Based on studies of functional results

• Focus on maintaining hip range of motion

Contracture release

Especially unilateral hip adduction and flexion contractures

HIP CONTRACTURES

Most common in low

lumbar level

Rare in sacral level

Velocity

Upper extremity

demand

Anterior pelvic tilt

HIP FLEXION CONTRACTURE HIP FLEXION CONTRACTURE

Physical exam:

Thomas test

Gait:

• Increased hip flexion during

mid-stance

• Increased anterior pelvic tilt

Forward lean of upper body

Increased lumbar lordosis

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First 2 years of life: hip flexion deformity tends to

decrease

Treatment rarely indicated in this group

>2 years of age:

Specific treatment recommendations based on functional

level of involvement

HIP FLEXION CONTRACTURE: TREATMENT TREATMENT: THORACIC, HIGH-LUMBAR

Flexion contracture < 30-40°

◦ Often tolerated if does not interfere w/ orthotic

use/ ambulation

Flexion contracture > 30-40°

◦ If patient attempts to walk w/ RGO

◦ Very short stride length

◦ Increased lumbar lordosis

Treatment indicated:

◦ Facilitate use of orthosis for standing/ walking

◦ Provide adequate ROM to sit comfortably in

wheelchair, lie supine in bed

Ileofemoral approach

Start with:

• Tensor fascia lata

• Sartorius

• Rectus femoris

• Iliopsoas

If needed, anterior capsulotomy

of hip joint

TREATMENT: THORACIC, HIGH-LUMBAR

SURGICAL TECHNIQUE

Post-operative management:

Short period of full-time use of

total body splint (~2 weeks)

Followed by night-time

bracing + aggressive physical

therapy


Very severe cases: contracture > 60°

If pressure sores are a problem and soft tissue release

alone is not enough:

Hip flexor lengthening +

Proximal femur extension osteotomy

AO blade plate for fixation


Hip flexion contractures can cause major functional

impairment

In patient who walks with AFOs + crutches

HFC > 20°:

• can cause significant anterior pelvic tilt

decreased walking velocity

increased demand on upper extremities

greater energy cost

TREATMENT: LOW-LUMBAR, SACRAL

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When surgery is indicated must take

care to preserve hip flexor power

Release rectus femoris and TFL

Detach sartorius from ASIS, reattach to

AIIS

IF iliopsoas lengthening is necessary,

◦ Do intramuscular lengthening above the pelvic

brim

◦ NEVER release distally in ambulatory patients!

Loss of hip power, inability to forcibly flex hip vs.

gravity

TREATMENT: LOW-LUMBAR, SACRAL HIP ADDUCTION CONTRACTURE

Surgical treatment indicated:

• When contracture interferes with

function

HIP ADDUCTION CONTRACTURE

Adductor longus and gracilis • Myotomy

Part of adductor brevis if

needed

• Protect obturator nerve

Goal = at least 60° abduction


Post-operative management:

Abduction wedge full-time for short period (~12 days)

Followed by night-time wedge + aggressive physical therapy


Severe recalcitrant cases:

Subtrochanteric valgus osteotomy of the proximal femur

• May be necessary to achieve sufficient abduction to improve

pelvic obliquity

Severe stiffness of hip joint

Patients who have had attempted surgical

treatment

Major problem

HIP STIFFNESS

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One option: Castle procedure

• Resection of proximal femur

• Capsular flap closed over acetabulum

Goal = improved ROM

Disadvantages:

• Need for post-op traction

• High risk of heterotopic ossification

HIP STIFFNESS

McHale osteotomy =

• Femoral head resection +

proximal femur valgus

osteotomy

In patients with CP:

• Allows good ROM

• Improves sitting ability

• Eases perineal care

ANOTHER OPTION?

McHale et al (J Pediatr Orthop 1990)

REFERENCES

Asher M, Olson J. Factors affecting the ambulatory status of patients with spina bifida cystica. J Bone Joint Surg Am 1983;65:350-356.

Barden GA, Meyer LC, Stelling FH III. Myelodysplastics—fate of those followed for twenty years or more. J Bone Joint Surg Am 1975;57: 643-647.

Bazih J, Gross RH. Hip surgery in the lumbar level myelomeningocele patient. J Pediatr Orthop 1981; 1(4):405-11.

Castle ME, Schneider C. Proximal femoral resection-interposition arthroplasty. J Bone Joint Surg Am 1978;60:1051-1054.

Cruess RL, Turner NS. Paralysis of hip abductor muscles in spina bifida: results of treatment by the Mustard procedure. J Bone Joint Surg Am 1970;52:1364-1372.

Dias L. Orthopaedic care in spina bifida: past, present and future. Dev Med Child Neur 2004;46:579.

Dias L (2002) Myelomeningocele and intraspinal lipoma. In: Sponseller PD (ed) Orthopaedic knowledge update: pediatrics 2nd edn. American Academy of Orthopaedic Surgeons, pp 249–259

Feiwell E. Surgery of the hip in myelomeningocele as related to adult goals. Clin Orthop 1980;148:87-93.

Feiwell E, Sakai D, Blatt T. (1978) The effect of hip reduction on function in patients with myelomeningocele: potential gains and hazards of surgical treatment. J Bone Joint Surg Am 60: 169–173.

Gabrieli APT, Vankoski SJ, Dias LS, Milani C, Lourenco A, Filho JL, Novak R (2003) Gait analysis in low lumbar myelomeningocele patients with unilateral hip dislocation or subluxation. J Pediatr Orthop 23:330–334

REFERENCES

McHale KA, Bagg M, Nason SS. Treatment of the chronically dislocated hip in adolescents with cerebral palsy with femoral head resection and subtrochanteric valgus osteotomy. J Pediatr Orthop 1990; 10(4): 504-509.

Selber P, Dias L. Sacral-level myelomeningocele: long-term outcome in adults. J Pediatr Orthop 1998;18:423-7.

Sharrard WJW. Long-term follow-up of posterior transplant for paralytic dislocation of the hip. J Bone Joint Surg Br 1970;52:551-556.

Sherk HH, Ames MD. Functional results of iliopsoas transfer in myelomeningocele hip dislocations. Clin Orthop Relat Res 1978;137:181-186.

Sherk HH, Uppal GS, Lane G, et al. Treatment versus non-treatment of hip dislocations in ambulatory patients with myelomeningocele. Dev Med Child Neurol1991;33:491-494.

Swaroop VT, Dias LS. What is the optimal treatment for hip and spine in myelomeningocele? In: Wright JG, ed. Evidence-based orthopaedics. Amsterdam, the Netherlands: Elsevier Health Sciences, 2008:273-277.

Swaroop VT. Dias L. Orthopedic management of spina bifida. Part I: hip, knee, and rotational deformities. J Child Orthop 2009;3:441-449.

Thomson JD, Segal LS. Orthopedic management of spina bifida. Dev Disabil Res Rev 2010;16:96-103.

Williams JJ, Graham GP, Dunne KB, Menelaus MB (1993) Late knee problems in myelomeningocele. J Pediatr Orthop 13:701–703



MYELOMENINGOCELE

Knee- crouch gait Luciano Dias, MD

INTRODUCTION


COMMON IN SPINA BIFIDA

LOW LUMBAR/SACRAL LEVEL

INCREASE OXYGEN COST

SURGICAL TREATMENT

FLEXION CONTRACTURE

> 15 TO 20 DEGREES

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9/2/11


CROUCH GAIT

FMS 6/6/6

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40-50%

20-30%

POWER GENERATION

MUSCLES

20-30%

SACRAL LEVEL

AFO/ NO CRUTCHES NO GASTROSOLEUS

WEAK GLUTEUS

NORMAL QUADRICEPS

LOW LUMBAR LEVEL

AFO/CRUTCHES NO GASTROSOLEUS

NO GLUTEUS

NL QUADRICEPS

NL HAMSTRINGS

CROUCH GAIT

These patterns of muscle weakness lead to a

gradual increase of knee flexion during the stance

phase of gait which, in turn, can lead to the

development of a gradual contracture of the knee

capsule and hamstrings, seen usually around the

age of 10

CROUCH GAIT

INCREASE OXIGEN COST

INCREASE OXIGEN CONSUMPTION

DIRECT RELATION WITH THE AMOUNT OF KNEE FLEXION DEFORMITY

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SURGICAL PROCEDURE

PATIENT IN PRONE

TRANSVERSE INCISION 1 CM ABOVE THE CREASE

SELECTIVE LENGTHENING MEDIAL HAMS AND BICEPS

THE MEDIAL AND LATERAL ORIGINS OF THE GASTROCNEMIUS ARE FREED FROM THE

RESPECTIVE FEMORAL CONDYLES

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INCISION

Post op

LL CAST

3 weeks

SURGICAL PROCEDURE

THE POSTERIOR KNEE CAPSULE IS EXPOSED

POSTERIOR CAPSULECTOMY

POSTERIOR CRUCIATE LIGAMENT IS LEFT INTACT

SKIN CLOSURE- INTERRUPTED SUTURE

LONG LEG CAST

KNEE IN FULL EXTENSION

POST OP

IMMOBILIZATION- 3 WEEKS

IF FULL EXTENSION NOT ACHIEVED AT THE TIME OF SURGERY

CAST CHANGE IN ONE WEEK

AFTER CAST REMOVAL

AFO OR GRAFO

KNEE IMMOBILIZER

PHYSICAL THERAPY

RESULTS - CLINICAL

PRE OP FLEXION

CONTRACTURE

24.9 DEGREES

POST OP FLEXION

CONTRACTURE

5.9 DEGREES

P=0.001

0

5

10

15

20

25

1st Qtr

PRE OP

POST OP

WALKING VELOCITY

PRE OP

72.2 %

POST OP

80.0 %

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PRE/POST GA

MYELOMENINGOCELE

GRADUAL DEVELOPMENT

MUSCLE WEAKNESS

INCREASE HEIGHT/WEIGHT

OVER THE AGE OF 10

CONTRACTURE OF THE POSTERIOR KNEE CAPSULE

MOST IMPORTANT

CONCLUSIONS

POSTERIOR KNEE CAPSULECTOMY

SELECTIVE LENGTHENING OF THE HAMSTRINGS

LEAD TO A SIGNIFICANT IMPROVEMENT OF THE

CHILDS GAIT

CONCLUSIONS

INDICATION FOR SURGERY

SACRAL LEVEL

LOW LUMBAR LEVEL

KFC HIGHER THAN 15 TO 20 DEGREES

KNEE FLEXION AT MID STANCE > 30

DEGREES

PRE OP GA IS IMPORTANT IN THE DECISION

IF GAIT ANALYSIS IS NOT AVAILABLE

THE DEGREE OF KNEE FLEXION DURING GAIT IS

DOUBLE FROM WHAT IS MEASURED ON CLINICAL

EXAM

SURGICAL TREATMENT IS INDICATED WHEN KNEE

FLEXION CONTRACTURE IS 15 DEGREES OR

HIGHER

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CROUCH GAIT TREATMENT

LOW LUMBAR/ SACRAL

Knee Flexor Lengthening - Hamstring Lengthening and Posterior Capsulotomy (low level)

Hip Flexor Lengthening( if present)

CROUCH GAIT

KNEE FLEXOR RELEASE CAN BE USED UP TO 45

DEGREES

IF THERE IS RECURRENCE

SUPRACONDYLAR EXTENSION OSTEOTOMY

SUPRACONDYLAR EXTENSION

OSTEOTOMY INTERNAL FIXATION RIGHT ANGLE PLATE

NO NEED FOR PATELLA ADVANCEMENT

LLC 6 WEEKS

GROUND REACTION AFO

CASE 5: HIP AND KNEE FLEXION

CONTRACTURE CROUCH GAIT (SF)

Age: 13 years

High sacral level

Bilateral hip flexion contractures

Bilateral knee flexion contractures

FMS 5/5/3

No Shunt

CASE 5: PRE-OP ROM/MMT CASE 5: PRE-OP KINEMATIC DATA

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CASE 5: HIP AND KNEE FLEXION CONTRACTURE

(SF)

Surgical Treatment

• Bilateral iliopsoas lengthening above the brim

• Bilateral knee flexor lengthening

Post Op

• Total body splint-10 days

• Long leg cast- 3 weeks

• Knee immobilizer

• Physical therapy strengthening

• Gait training

CASE 5: POST-OP ROM/MMT

CASE 5: POST-OP KINEMATIC DATA

Left Side Right Side CONTROVERSIES IN ORTHOPAEDIC


MYELOMENINGOCELE

Rotational deformities Rachel M. Thompson, MD

Torsional deformities of the tibia are common in

patients with spina bifida

Internal tibial torsion

• Fixed, congenital deformity

• Frequently associated with clubfoot

External tibial torsion

• Acquired deformity likely due to muscle imbalance

• Often associated with shortened fibula and valgus

deformity of the ankle

* Neither will spontaneously resolve

Dias LS, Jasty MJ, Collins P. Rotational deformities of the lower limb in myelomeningocele. Evaluation and treatment. The Journal of bone and joint surgery. American volume. Feb 1984;66(2):215-223.

TIBIAL TORSION MAY LEAD TO:

• Significant gait abnormalities • Biomechanics • Velocity

• Frequent falls (internal) • Difficulty with brace tolerance • Skin breakdown & excessive shoe wear • Pain: knee/foot • Hindfoot valgus pes planus • Lever arm disease

Fraser RK, Menelaus MB. The management of tibial torsion in patients with spina bifida. The Journal of bone and joint surgery. British volume. May 1993;75(3):495-497.

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TREATMENT FOR AMBULATORY PATIENTS

Goals: • minimize bracing requirements

• achieve as normal a gait pattern as possible

Surgical consideration when gait function is

impacted • Internal frequent tripping 2/2 difficulty with foot clearance

• External crouch gait (lever arm disease)

• External knee valgus stress

Lim R, Dias L, Vankoski S, Moore C, Marinello M, Sarwark J. Valgus knee stress in lumbosacral myelomeningocele: a gait-analysis evaluation. Journal of pediatric orthopedics. Jul-Aug 1998;18(4):428-433.

Gage JR. Gait analysis in cerebral palsy. London, New York: Mac Keith Press; Distributor Cambridge University Press; 1991.

Compromised knee

extension moment

Knee axis

LEVER ARM DISEASE

ETT > 20o may lead to crouch

• AFO unable to achieve extension moment for knee during stance

Improving ETT will improve effectiveness of AFO in achieving knee extension

Internal rotation osteotomy to allow for knee extension during stance phase

Knee

extension

moment

Dunteman RC, Vankoski SJ, Dias LS. Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele. Journal of pediatric orthopedics. Sep-Oct 2000;20(5):623-628.

VALGUS KNEE STRESS

Excessive ETT can also lead to valgus stress at the knee joint

Increased ETT likely to result in abnormal internal varus knee moment

TFA > 20o significantly increases this stress

*not controllable with orthotics over 20o

Abnormal stress may predispose the knee to late arthrosis

Lim R, Dias L, Vankoski S, Moore C, Marinello M, Sarwark J. Valgus knee stress in lumbosacral myelomeningocele: a gait-analysis evaluation. Journal of pediatric orthopedics. Jul-Aug 1998;18(4):428-433.

VALGUS KNEE STRESS

Instability, pain, arthritis in adulthood

• 72 community ambulators > 23 years old

• 24% reported significant knee symptoms

• WITH weakness of hip abductors, gastroc-soleus characteristic gait pattern:

• Abductor lurch

• Knee in valgus + flexion during stance

• To propel forward: swivel push-off on fixed pronated foot

Stress ↑ @medial ligaments ↑ @articular surface

Williams JJ, Graham GP, Dunne KB, Menelaus MB. Late knee problems in myelomeningocele. Journal of pediatric orthopedics. Nov-Dec 1993;13(6):701-703.

Gait analysis: improved understanding Identification of multiple factors valgus stress

Internal hip rotation

Lateral trunk motion

Knee flexion

External tibial torsion

Valgus Knee Stress VALGUS KNEE STRESS: TREATMENT

Correct rotational deformities

Leads to significant improvement in knee stress and pain

May prevent late degenerative changes

Must also correct:

Knee Flexion Contracture

Hindfoot Valgus

Encourage use of AFO + crutches

↓ Pelvic obliquity/ rotation

↑ Stance-phase stability

↓ Stress at knee joint Lim R, Dias L, Vankoski S, Moore C, Marinello M, Sarwark J. Valgus knee stress in lumbosacral myelomeningocele: a gait-analysis evaluation. Journal of pediatric orthopedics. Jul-Aug 1998;18(4):428-433. Dunteman RC, Vankoski SJ, Dias LS. Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele. Journal of pediatric orthopedics. Sep-Oct 2000;20(5):623-628. Swaroop VT, Dias L. Orthopedic management of spina bifida. Part I: hip, knee, and rotational deformities. Journal of children's orthopaedics. 2009;3(6):441-449. Selber P, Dias L. Sacral-level myelomeningocele: long-term outcome in adults. J Pediatr Orthop 1998;18:423-7.

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NON-OPERATIVE TREATMENT

Twister cables attached to AFOs

Controls in/out-toeing

Improve gait

Not expected to correct underlying

osseous deformity

Use until patient old enough for

surgical correction

OPERATIVE TREATMENT

Indications:

• > 6 years old

• Severe rotational deformity (usually >20o)

• Gait abnormalities

• Difficulty with orthotic fitting/ skin breakdown

• Pain

3D gait analysis pre-operatively: document gait pattern

and help determine extent of correction needed

Dias LS, Jasty MJ, Collins P. Rotational deformities of the lower limb in myelomeningocele. Evaluation and treatment. The Journal of bone and joint surgery. American volume. Feb 1984;66(2):215-223. Fraser RK, Menelaus MB. The management of tibial torsion in patients with spina bifida. The Journal of bone and joint surgery. British volume. May 1993;75(3):495-497.

TIBIA DEROTATIONAL OSTEOTOMY

Distal vs. Proximal

• Krengel & Staheli: improved complication profile with distal osteotomy

• Selber: major complication rate distal 5.3%

• Mednick/Swaroop/Dias: major complication rate distal 3.1%

Tibia Derotational Osteotomy

Plate vs. K-wire fixation

• Ryan et. al: delayed union rate with k-wire fixation 4%

• Mednick/Swaroop/Dias: delayed union rate with plate fixation 2.3%

• Martin et. al: complication rate with k-wire fixation 33%

• Mednick/Swaroop/Dias: total complication rate with plate fixation 33%

Distal vs. Proximal

Tibia only vs. Tibia & fibula osteotomy

• Manouel & Johnson, Rattey & Hyndman: Higher trend toward posterior/coronoal angulation at osteotomy with fibular osteotomy

• Mednick/Swaroop/Dias: malunion 0%

Plate vs. K-wire fixation

Distal vs. Proximal

TIBIA DEROTATIONAL OSTEOTOMY OPERATIVE TECHNIQUE

Distal tibia and fibula derotation osteotomy

• Tibia osteotomy just above the

distal tibial physis

• Fibula osteotomy through a

separate incision Osteotomy created using multiple drill holes

AO limited-contact dynamic compression

plate (5- or 6-hole plate)

Incision closed over a drain with

interrupted, non-absorbable sutures

Dodgin DA, De Swart RJ, Stefko RM, Wenger DR, Ko JY. Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. Journal of pediatric orthopedics. Jan-Feb 1998;18(1):95-101. Mednick RE, Eller EB, Swaroop VT, Dias L. Outcomes of Tibial Derotational Osteotomies Performed in Patients With Myelodysplasia. Journal of pediatric orthopedics. 2015;35(7):721-724.

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POST-OPERATIVE CARE

Short leg cast

• First 3 weeks: NWB

• Second 3 weeks: WBAT

Cast and sutures removed at ~6

weeks

Placed into AFO

Aggressive rehab

ASSOCIATED DEFORMITIES

Important to recognize any associated osseous deformity or

muscle imbalance:

• ITT: spastic anterior tibialis may require tenotomy

• ETT: look for any concomitant hindfoot valgus

Swaroop VT, Dias L. Orthopedic management of spina bifida. Part I: hip, knee, and rotational deformities. Journal of children's orthopaedics. 2009;3(6):441-449.

FUNCTIONAL RESULTS

Surgical correction of torsional deformities

• Improved gait parameters

• Improved range of motion

• KAFO AFO requirement post-operatively

ETT:

• Osteotomy improves knee extension during stance

• May delay/prevent late degenerative changes in knee

80-90% patients

Dias LS, Jasty MJ, Collins P. Rotational deformities of the lower limb in myelomeningocele. Evaluation and treatment. The Journal of bone and joint surgery. American volume. Feb 1984;66(2):215-223. Fraser RK, Menelaus MB. The management of tibial torsion in patients with spina bifida. The Journal of bone and joint surgery. British volume. May 1993;75(3):495-497. Stefko RM, de Swart RJ, Dodgin DA, et al. Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy. Journal of pediatric orthopedics. Jan-Feb 1998;18(1):81-87. Dunteman RC, Vankoski SJ, Dias LS. Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele. Journal of pediatric orthopedics. Sep-Oct 2000;20(5):623-628.

Walton DM, Liu RW, Farrow LD, et al. Proximal tibial derotation osteotomy for torsion of the tibia: a review of 43 cases. J Child Orthop. 2012;6:81–85.

Dodgin DA, De Swart RJ, Stefko RM, et al. Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. J Pediatr Orthop. 1998;18:95–101.

Selber P, Filho ER, Dallalana R, et al. Supramalleolar derotation osteotomy of the tibia, with T plate fixation. Technique and results in patients with neuromuscular disease. J Bone Joint Surg Br. 2004; 86:1170–1175.

McNicol D, Leong JC, Hsu LC. Supramalleolar derotation osteotomy for lateral tibial torsion and associated equinovarus deformity of the foot. J Bone Joint Surg Br. 1983;65:166–170.

Krengel WF III, Staheli LT. Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and distal osteotomy levels. Clin Orthop Relat Res. 1992;283:285–289.

Ryan DD, Rethlefsen SA, Skaggs DL, et al. Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy. J Pediatr Orthop. 2005;25:84–88.

Martin SL, Samartzis D, Gerson A, et al. Tibial Rotational Osteotomies in Patients with Myelodysplasia: Outcomes and Risk Factors. E-poster presented at 2009 POSNA Annual Meeting April 2009, 2009; Boston, MA

Despite functional improvement… Reported complication rates widely variable:

• Mixed idiopathic/neuromuscular population: 4.8-13%

• Myelodysplasia population: 28-33% + 31% re-operation rate

Retrospective chart review

All patients with neural tube disorders undergoing distal tibia

derotation osteotomy between 1985 – 2010

• Lumbar or sacral level myelodysplasia

• Symptomatic deformity: >20o

• Affecting brace wear, gait biomechanics or velocity

• >5y age

• >2y follow-up

RESULTS

82 patients (129 limbs)

Average age at index surgery: 9.85 years

Average follow-up from index surgery:7.15 years

Of the 128 limbs

• 29% correction of internal tibial torsion

• 71% correction of external tibial torsion

Average derotation:27.5O (+/-12.3O)

Results maintained at final f/u: 24.5O (+/- 13O)

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RESULTS: COMPLICATIONS

• All superficial infections treated successfully with oral antibiotics

• Deep infection required surgical debridement without ROH

• 1 fracture occurred about the plate 4 months post-surgery, treated with

casting alone

RESULTS: RE-DEROTATION

Repeat derotation surgery occurred at 5.0 ± 2.5 years after index

surgery

Total reoperation (complications & re-derotation) = 20%

RESULTS

Age at initial surgery:

• No effect on complication rate (p = 0.37)

• Or need for repeat derotation (p = 0.13)

Level of spinal involvement:

• Not associated with complication rate (p = 0.46)

• Lumbar level associated with significantly higher rate of repeat

derotation (10.85%) compared to sacral level (5.43%) (p = 0.03)

REFERENCES

1. Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg. 2003;11:312–320.

2. Staheli LT. Torsion—treatment indications. Clin Orthop Relat Res. 1989;247:61–66.

3. Dias LS, Jasty MJ, Collins P. Rotational deformities of the lower limb in myelomeningocele. Evaluation and

treatment. J Bone Joint Surg Am. 1984;66:215–223.

4. Fraser RK, Menelaus MB. The management of tibial torsion in patients with spina bifida. J Bone Joint Surg Br.

1993;75:495–497.

5. Staheli LT, Corbett M, Wyss C, et al. Lower-extremity rotational problems in children. Normal values to guide

management. J Bone Joint Surg Am. 1985;67:39–47.

6. Lim R, Dias L, Vankoski S, et al. Valgus knee stress in lumbosacral myelomeningocele: a gait-analysis

evaluation. J Pediatr Orthop. 1998;18:428–433.

7. Stefko RM, de Swart RJ, Dodgin DA, et al. Kinematic and kinetic analysis of distal derotational osteotomy of

the leg in children with cerebral palsy. J Pediatr Orthop. 1998;18:81–87.

8. Walton DM, Liu RW, Farrow LD, et al. Proximal tibial derotation osteotomy for torsion of the tibia: a review of

43 cases. J Child Orthop. 2012;6:81–85.

9. Dodgin DA, De Swart RJ, Stefko RM, et al. Distal tibial/fibular derotation osteotomy for correction of tibial

torsion: review of technique and results in 63 cases. J Pediatr Orthop. 1998;18:95–101.

10. Mednick RE, Eller EB, Swaroop VT, Dias L. Outcomes of Tibial Derotational Osteotomies Performed in Patients With Myelodysplasia. Journal of pediatric orthopedics. 2015;35(7):721-724.

11. Selber P, Filho ER, Dallalana R, et al. Supramalleolar derotation osteotomy of the tibia, with T plate fixation.

Technique and results in patients with neuromuscular disease. J Bone Joint Surg Br. 2004; 86:1170–1175.

12. Swaroop VT, Dias L. Orthopedic management of spina bifida. Part I: hip, knee, and rotational

deformities. Journal of children's orthopaedics. 2009;3(6):441-449.

REFERENCES

13. McNicol D, Leong JC, Hsu LC. Supramalleolar derotation osteotomy for lateral tibial torsion and associated

equinovarus deformity of the foot. J Bone Joint Surg Br. 1983;65:166–170.

14. Krengel WF III, Staheli LT. Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and

distal osteotomy levels. Clin Orthop Relat Res. 1992;283:285–289.

15. Ryan DD, Rethlefsen SA, Skaggs DL, et al. Results of tibial rotational osteotomy without concomitant fibular

osteotomy in children with cerebral palsy. J Pediatr Orthop. 2005;25:84–88.

16. Martin SL, Samartzis D, Gerson A, et al. Tibial Rotational Osteotomies in Patients with Myelodysplasia:

Outcomes and Risk Factors. E-poster presented at 2009 POSNA Annual Meeting April 2009, 2009; Boston,

MA.

17. Davids JR, Davis RB, Jameson LC, et al. Surgical management of persistent intoeing gait due to increased

internal tibial torsion in children. J Pediatr Orthop. 2014;34:467–473.

18. Manouel M, Johnson LO. The role of fibular osteotomy in rotational osteotomy of the distal tibia. J Pediatr

Orthop. 1994;14:611–614.

19. Rattey T, Hyndman J. Rotational osteotomies of the leg: tibia alone versus both tibia and fibula. J Pediatr

Orthop. 1994;14:615–618.

20. Krackow KA, Mandeville DS, Rachala SR, et al. Torsion deformity and joint loading for medial knee

osteoarthritis. Gait Posture. 2011;33:625–629.

21. Gage JR. Gait Analysis in Cerebral Palsy. London, New York: Mac Keith Press; Distributor Cambridge

University Press; 1991.

22. Dunteman RC, Vankoski SJ, Dias LS. Internal derotation osteotomy of the tibia: pre- and postoperative gait

analysis in persons with high sacral myelomeningocele. J Pediatr Orthop. 2000;20:623–628.

23. Williams JJ, Graham GP, Dunne KB, et al. Late knee problems in myelomeningocele. J Pediatr Orthop.

1993;13:701–703.



MYELOMENINGOCELE

Foot deformities Vineeta T. Swaroop, MD

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FOOT DEFORMITY

Foot deformity is present in almost all patients with

MM

• Can interfere with bracing to allow ambulation

• Cause difficulty with shoe wear

• Create cosmetic problems

• Lead to pressure sores

FOOT DEFORMITIES

Goals of treatment:

Plantigrade, flexible, braceable foot

Preserve range of motion

Avoid pressure sores

FOOT DEFORMITIES

Basic principles:

Intervene early to maintain flexible foot/ prevent fixed bony deformity • Serial casting

• Bracing

• Surgery

Tendon excisions

Osteotomies allow correction while preserving joint motion

AVOID ARTHRODESIS

Use AFO after surgery to maintain correction

FOOT DEFORMITIES

Basic principles:

AVOID ARTHRODESIS

• Resulting stiffness + insensate foot

Neuropathic skin changes

Pressure sores

Osteomyelitis

Amputation

• When needed, bony procedures should be extra-articular,

preserving motion

CLUBFOOT

Most common foot deformity in MM

• 30-50% of patients with MM

Incidence varies with neurologic level

• 90% thoracic/lumbar

• 50% sacral

Akbar et al J Bone Joint Surg 2009

Westcott et al Radographics 1992

de Carvalho Neto et al J Pediatr Orthop 1996

CLUBFOOT

Different from idiopathic clubfoot:

• Severely rigid deformity

• Recalcitrant to treatment

• Propensity to recur

• Often associated with severe internal

tibial torsion

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CLUBFOOT - ETIOLOGY

Multifactorial

• Spasticity

• Intrauterine positioning

• Contractures

• Muscle imbalance

i.e. Low-lumbar level patient:

• Clubfoot may develop in part due to retained

activity/contracture of tibialis anterior + functional absence

of peroneals

CLUBFOOT - TREATMENT

Traditional teaching = non-surgical management

rarely successful

• Splinting

• Serial casting

• Stretching

Extensive soft tissue release (PMLR) surgery

necessary for correction

Skin breakdown,

recurrence


Ponseti method

Multiple studies have reported early results in clubfeet

associated with MM

• No long-term follow-up

What is standard of care for clubfoot treatment in

spina bifida?

Should Ponseti method be attempted in all patients?

CLUBFOOT – PONSETI METHOD

Ponseti method:

28 clubfeet in MM

Initial correction achieved in 27/28 (96%)

Average follow-up 34 months:

• Relapse occurred in 68%

• 4/28 (14%) required extensive soft tissue releases

Complications:

• 9 feet (32%) blistering in foot abduction orthosis

6/9 had recurrence while out of brace requiring repeat casting

• 3 feet (11%) cast slippage leading to complex clubfoot deformity

• 2 patients with distal tibial fractures

Gerlach et al J Bone Joint Surg 2009


Ponseti method:

9 clubfeet in MM

Initial correction achieved in all feet

Average follow-up 33 months:

• 5 feet (56%) with recurrence

• 3 (33%) required extensive soft tissue releases

Complications:

• 2 feet (22%) skin breakdown

Janicki et al J Pediatr Orthop 2009


Ponseti method:

24 clubfeet in patients with ‘spinal dysraphism’

Initial correction achieved in 22/24 (92%)

Average follow-up 4 years:

• 13/22 feet (60%) with recurrence

• Relapse occurred at mean of 3.2 years after initial

correction

Complications:

• Pressure sores in 4 feet

Dunkley et al J Child Orthop 2015

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CLUBFOOT - PONSETI METHOD

Ponseti method:

Initial correction in 92-100% feet

56-68% recurrence

High rate of complications: skin breakdown, fractures

Ponseti method can be useful in decreasing need for extensive soft-tissue release

BUT families should be counseled about: • High risk of recurrence

• Potential for need for further treatment

• Risk of skin breakdown, fractures


If soft-tissue release is indicated

Surgical treatment should consist of a radical

posteromedial-lateral release using a cincinnati

incision

All tendons excised (not lengthened)

Subtalar, calcaneocuboid, and talonavicular joints

completely released

Separate plantar release may be needed through

plantar incision

Optimum age is 10-12 months

CLUBFOOT – SURGICAL TECHNIQUE

Improved results have been shown with use of temporary k-wire to derotate talus in ankle mortise

K-wire placed into posterolateral aspect of talus • Rotate talus medially

• Navicular reduced on talar head

Second k-wire driven through body of talus into navicular to hold reduction • Temporary k-wire removed

Use additional k-wire to maintain talocalcaneal alignment


CLUBFOOT – POSTOPERATIVE MANAGEMENT

Long leg posterior mold splint for 1st 2 weeks

• Foot in slight equinus

• Decrease tension on interrupted sutures used for skin

closure

Change to long leg cast with foot in corrected position

x 6 weeks

Day and night-time AFOs used to maintain correction

for long-term

CLUBFOOT – SURGICAL RESULTS

Good results reported in 61-83% of patients

Outcome varies with motor level of involvement

• 50% poor results in thoracic/high-lumbar vs.

• 11% poor results in low-lumbar/ sacral


Akbar et al J Bone Joint Surg 2009


Flynn et al J Pediatr Orthop B 2004

CLUBFOOT – SURGICAL RESULTS

Partial or complete recurrence occurs in 20-50% after

primary surgical correction

• Adduction deformity common

• Treat with “double C osteotomy”

For complete recurrence talectomy

Lourenco et al J Pediatr Orthop 2001

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CLUBFOOT SUMMARY

What is the standard of care?

Ponseti

• Initial correction in 92-100% feet

• 56-68% recurrence

• High rate of complications: skin breakdown, fractures

PMLR

• Good results in 61-83% (varies by motor level)

• Partial or complete recurrence in 20-50%

VERTICAL TALUS

Rigid rocker-bottom flatfoot deformity

~10% patients with MM

Occurs in 2 forms:

• Congenital – more common

• Developmental

VERTICAL TALUS

Dorsolateral dislocation of the

talonavicular joint

Extreme, rigid plantar flexion of talus

• Talus is nearly vertical

Calcaneus in equinus, valgus

Fixed dorsiflexion of midfoot on

hindfoot

• Navicular dislocated dorsally and

laterally on talus

PATHOANATOMY

Fixed hindfoot equinus, valgus

• Due to contracture of Achilles and

peroneals

Rigid midfoot dorsiflexion

• Due to dislocation of navicular

Forefoot abducted, dorsiflexed

• Due to contractures of tibialis anterior

and toe extensors

CLINICAL EXAM

“A prominence in the sole from which the heel and

forefoot rise in a gentle curve.”

• Lloyd-Roberts and Spence

‘Persian slipper’

CLINICAL EXAM

Few posterior heel skin creases

Head of talus palpable on

plantarmedial aspect of foot

• Convex plantar surface

Crease overlying sinus tarsi

Not correctable by manipulation!

• Cannot create longitudinal arch

• Cannot reduce head of talus

• Cannot dorsiflex ankle

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CLINICAL EXAM

Rigid rockerbottom foot

Hindfoot: equinus, valgus

• Achilles tendon contracted

Midfoot: abducted, dorsiflexed

Forefoot: abducted, dorsiflexed

RADIOGRAPHIC EXAM

AP, lateral

Diagnosis confirmed with:

• Lateral in forced plantar flexion

• Lateral in forced dorsiflexion

AP:

• Midfoot valgus

• Talocalcaneal angle > 40°

(normal = 20-40°)

RADIOGRAPHIC EXAM

Before ossification of navicular, 1st

MT used as proxy

Forced plantar flexion lateral

• Persistent dorsal dislocation of TN

joint

• Meary’s angle > 20°

Forced dorsiflexion lateral

• Persistence of plantar flexion of talus

• Equinus position of calcaneus

TREATMENT

Goal = restore normal relationship between talus,

navicular, and calcaneus

• Provide plantigrade weight-bearing surface

Traditional treatment =

Complete posteromedial-lateral and dorsal release

• Between 10-12 months of age

TREATMENT

Dobbs method

Serial manipulation

Cast immobilization

Open talonavicular pin fixation

Percutaneous Achilles tenotomy

Excellent short-term results

TREATMENT

Foot stretched into

plantar flexion and

inversion while

counterpressure applied

to medial aspect of head

of the talus

Dobbs et al JBJS 2007

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TREATMENT

Foot position before TN pinning:

Maximum hindfoot varus

Forefoot adduction

Maximum plantar flexion


9/2/11


9/2/11


9/2/11


RESULTS – DOBBS METHOD (ALL ETIOLOGIES)

19 feet

At least 2y follow-up

Initial correction achieved in all cases • Average 5 casts

Final f/u: mean DF 25° , mean PF 33°

Recurrence in 3 patients • None had pin fixation of TN joint

Significant improvement in all radiographic parameters compared with pretreatment

All measured angles were within normal values for patient’s age

Dobbs et al J Bone Joint Surg 2006

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Significance of Case

Introduction

Patient Description

Surgical Intervention

Conclusions

Non-Operative Intervention

Response to Treatment

Correction of Congenital Vertical Talus Using the Dobbs Method

in a Patient with Myelomeningocele: a Case Report

Stacy Frye, MD1,2; Vineeta Swaroop, MD1,3

1Children's Memorial Hospital, Chicago, IL; 2Geisinger Medical Center, Danville, PA; 3Rehabilitation Institute of Chicago

Congenital vertical talus is an uncommon disorder of the foot characterized by fixed dorsal

dislocation of the navicular bone on the talar head and neck and fixed equinus contracture of the

hindfoot. A rigid form of congenital vertical talus is seen in up to 10% of patients with

myelomeningocele; this deformity is typically more difficult to correct and has an increased

tendency for recurrence. In these patients, the current preferred treatment is a one-stage

comprehensive release. The Dobbs method, which incorporates serial casting based on principles

of Ponseti casting, pinning the talonavicular joint, and tendo-Achilles lengthening, was recently

introduced as a less invasive, yet effective, alternative. However, the Dobbs articles consider

neuromuscular disorders as exclusion criteria.

This is the first reported case of the Dobbs method being successfully used to treat congenital

vertical talus in a patient with myelomeningocele. No reports in the English medical literature could

be found documenting any previous cases.

The patient is a 20 month old male born with lower lumbar level myelomeningocele. He presented to

orthopaedics at 5 weeks of age with bilateral dorsiflexion contractures. Radiographs confirmed

bilateral vertical talus (normal spine & pelvis films).

Serial long-leg casting using the Dobbs method was started at 8 weeks of age. The first set of casts

was placed for 2 weeks. Subsequent casts were each placed for 1 week, with molding in

plantarflexion, inversion, adduction and toe flexion.

Radiographs taken after 4 weeks of serial casting (3 sets of casts) showed improvement in talar

positioning bilaterally (less obliquity, better alignment with first metatarsals). Examination at that time

showed neutral positioning, improved plantarflexion and forefoot adduction, and medial longitudinal

arch present.

He continued to show progressive flexibility at weekly follow-up. Radiographs taken at 14 weeks of

age, after 6 weeks of serial casting (5 sets of casts), confirmed reduction of the talonavicular joint.

Right Right Left Left

Bilateral tendo-Achilles lengthening and open talonavicular pinning were done at 15 weeks of age.

Intraoperative photographs showing skin incisions over the medial aspect of the talonavicular joint

(a) and over the Achilles tendon (b). Open visualization of the talonavicular joint (c) and Kirschner

wire placement across the reduced talonavicular joint (d).

Intraoperative fluoroscopy confirming reduction of the talonavicular joint with Kirschner wire (e, f).

Intraoperative photographs demonstrating Kirschner wire placement across the talonavicular joints as

well as talocalcaneal joints to improve stretching during immobilization (g, h). Long leg casts placed

post-operatively.

Pins and sutures removed at 3 weeks post surgery. Post-operative examination demonstrated

improved talonavicular motion and excellent correction of equinus and forefoot position (a, b).

Custom ankle-foot orthoses (AFOs) and physical therapy started at 1 month post surgery. AFOs

worn 23 hours/day through 12 months of age, then transitioned to night time use and while in

stander. (He began weightbearing in AFOs with stander at 9 months old.)

Repeat evaluations and radiographs through 20 months of age (c, d) confirmed maintenance of

correction.

The goal of this case report is to discuss the successful treatment of congenital vertical talus in a

myelomeningocele patient using the Dobbs method. The treatment of vertical talus in patients with

myelomeningocele is complicated by lower limb paralysis, sensory loss, risk of skin breakdown and

a more rigid deformity. Given that approximately ½ of patients with vertical talus have neurologic

disorders, a goal of this case report is to raise awareness regarding a less invasive alternative and

stimulate discussion regarding its potential for treating this population.

(a)

(a)

(b)

(b) (c) (d)

(c) (d)

(e) (f) (g) (h)

RESULTS – DOBBS METHOD FOR NON-IDIOPATHIC FEET

25 feet (6 with MM)

>2y follow-up after surgery

Initial correction achieved in all

cases

• Average 5 casts

Significant improvement in all

radiographic parameters

5 (20%) feet had recurrence

• No recurrence in MM feet

Chalayon et al J Bone Joint Surg 2012

Extensive soft-tissue release:

Single-stage surgical correction

• Kodros, Dias J Pediatr Orthop 1999

Preferred over two-stage procedure

• Associated with complications: AVN of talus

VERTICAL TALUS: TREATMENT

Cincinnati incision

Achilles z-lengthened

Posterior capsules of tibiotalar and subtalar joints opened

Circumferential release subtalar joint

Release talonaviular joint • Medial/dorsal

Release calcaneocuboid joint if needed

Anterior (and posterior if needed) tibial tendons detached/ transferred

SINGLE-STAGE CORRECTION

K-wire placed into posterolateral talus

• Joystick to elevate talus

• While plantarflexing navicular and forefoot

Talonavicular and subtalar joints pinned

Extensor, peroneal tendons lengthened as needed thru 2nd incision


Very similar to clubfoot surgery…

Main difference is rotation of the talus:

Dorsiflexion instead of internal rotation


9/14/2015

31


Maintain elevation –

prevent swelling

Cast change in 2

weeks

Kodros, Dias J Pediatr Orthop 1999

42 feet

100%: good or fair results at final f/u

No wound complications or avascular necrosis of talus

Mild pain in 3 feet

All patients/ families satisfied with results

SINGLE-STAGE: RESULTS

REFERENCES

Akbar M, Bresch B, Seyler TM, et al. Management of orthopaedic sequelae of congenital spinal disorders. J Bone Joint Surg Am 2009;91:87-100.

Chalayon O, Adams A, Dobbs MB. Minimally invasive approach for the treatment of non-isolated congenital vertical talus. J Bone Joint Surg 2012;94:e73(1-7).

de Carvalho Neto J, Dias LS, Gabrieli AP. Congenital talipes equinovarus in spina bifida: treatment and results. J Pediatr Orthop 1996;16:782-5.

Dobbs MB, Purcell DB, Nunley R, et al. Early results of a new method of treatment for idiopathic congenital vertical talus. Surgical technique. J Bone Joint Surg Am2007;89(Suppl 2 Pt 1):111-121.

Dunkley M, Gelfer Y, Jackson D, et al. Mid-term results of a physiotherapist-led Ponseti service for the management of non-idiopathic and idiopathic clubfoot. J Child Orthop 2015;9:183-9.

Flynn JM, Herrera-Soto JA, Ramirez NF, et al. Clubfoot release in myelodysplasia. J Pediatr Orthop B 2004;13(4):259-262.

Gerlach DJ, et al. Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele. J Bone Joint Surg 2009;91:1350-9.

Janicki JA, Narayanan UG, Harvey B, et al. Treatment of neuromuscular and syndrome-associated (nonidiopathic) clubfeet using the ponseti method. J Pediatr Orthop 2009;29:393-7.

Kodros SA, Dias LS. Single-stage surgical correction of congenital vertical talus. J Pediatr Orthop 1999;19(1):42-48.

Lourenco AF, Dias LS, Zoellick DM, et al. Treatment of residual adduction deformity in clubfoot: the double osteotomy. J Pediatr Orthop 2001;21:713-718.

Westcott MA, Dynes MC, Remer EM, et al. Congenital and acquired orthopedic abnormalities in patients with myelomeningocele. Radiographics 1992;12:1155-1173.

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