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Year : 2005  |  Volume : 39  |  Issue : 4  |  Page : 248-253
Lower limb alignment in cerebral palsy


Physical Medicine & Rehabilitation Department, Swamy Vivekanand National Institute of Rehabilitation Training and Research, Olatpur, Bairoi, Cuttack, India

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   Abstract 

Background: Spasticity leading to tightness of muscle is disabling. Muscular activity is used for balance of motion and joint alignment rather than weight bearing. Change of joint position interferes with passage of ground reaction force leading to muscle fatigue. During ambulation center of mass changes beyond its range due to so many causes including abnormal hip, knee, ankle and foot motion leading to high energy expenditure.
Methods: Three hundred and sixty five lower limbs in 220 patients were operated by various methods described for hip, knee and ankle joint.
Results: Results were excellent to fair in two hundred cases and poor in twenty cases.
Conclusion: When cases taken up for surgery are selected with proper and repeated assessment, appropriate surgical procedures are performed in time then results of surgery are best in comparison with any other modalities of treatment and also achieved in a short time

Keywords: Cerebral palsy; Lower limb alignment.

How to cite this article:
Das S P, Singh D, Sahoo J, Prasad S V, Mohanty R N, Das S K. Lower limb alignment in cerebral palsy. Indian J Orthop 2005;39:248-53

How to cite this URL:
Das S P, Singh D, Sahoo J, Prasad S V, Mohanty R N, Das S K. Lower limb alignment in cerebral palsy. Indian J Orthop [serial online] 2005 [cited 2019 Mar 26];39:248-53. Available from: http://www.ijoonline.com/text.asp?2005/39/4/248/36613

   Introduction Top


Rehabilitation of the patient with cerebral palsy depends upon the restoration of muscle balance, proper alignment of joints and establishment of correct posture in the line of gravity. No therapeutic program can succeed with out attaining these goals.

Tightness or spasticity that prevents normal standing is a disability. In the normal standing posture ground reaction force (GRF ) passes from ground through the midfoot, anterior to ankle and knee and posterior to hip joint. Muscular activity is used for balance rather than to support the body. If tightness prevents complete extension of these joints relaxed standing cannot occur. When these joints are not fully extended, muscle support a part of weight and fatigue more rapidly and has less endurance for standing and ambulatory activities. Contraction of muscles to hold the body erect places more compressive forces on the joint resulting in rapid weakness and joint pain.

Center of mass (COM) of the body is a hypothetical point lying in front of second sacral vertebra. Its position changes due to various mechanisms including interchange between hip, knee, ankle and foot motion. If center of mass moves beyond its range during gait cycle there is high-energy expenditure during gait. Due to above reason cited it becomes essential to align the limb to achieve the above stated goals.

Physiotherapy, occupational therapy and botulinum toxin can achieve these objectives for a temporary period. Even if we come across some improvement by these methods all are worried about the time period. Botulinum toxin is costly. Now a days most of the parents are working and joint family concept is decreasing in India. So, there is a need for early result oriented service to cerebral palsy patients. For poor patients it is also time bound. Parents can actively participate in the management program maximum up to two years. So, service to be delivered within that period also. They are frustrated if not.

Taking all these points into concern more stress is given on surgical measures to restore power, align the joints and maintain posture after a course of therapy and assessment by surgeon, physical therapist, occupational therapist, psychologist and social worker. Surgical procedures to achieve these goals are well established [1],[2],[3],[4],[5],[6],[7] .

Orthopaedic surgery forms only one facet of treatment program. The object of surgery is to achieve these goals in a fixed period of time, facilitate the role of physiotherapist, occupational therapist and parents' simple.

Selection of cases for surgery is also a very important aspect of the management program. It is also the purpose of this paper to assess the results of various surgical procedures described. This experience has helped us to be aware of the benefits available to these children through properly selected surgical procedures in proper cases.


   Materials and methods Top


From 1996 to 2003, 2881 patients were examined. Out of these 1937 were male and 944 were females. There were 235 hemiplegics, 1935 diplegic and 711 quadriplegic. Out of 235 hemiplegics, 37 patients had left sided involvement and 198 right. Three hundred sixty five lower limbs in 220 cases were operated and 1306 procedures were undertaken. There were 75 hemiplegics and 145 diplegics. Age range of patients varies from four to 23 years. One limb needed minimum three incisions for most of the procedures. Minimum time needed for surgery in one limb is around one hour and were done under short IV Ketamine. Both limbs if needed operated in one sitting.

Common deformities we come across in lower limb are adduction, flexion, internal rotation and subluxation around hip joint [Figure - 1], and flexion or extension type deformities in knee joint. Equinus, calcaneus, valgus and varus deformity around ankle joint are some of the common deformities. Toe deformities like hallux valgus and flexion deformities of toes are encountered.

Muscle power of limb assessed in most of the cases by modified Ashworth's method. It was not possible to assess the muscle power in athetoids. But athetoids were taken up for surgery. The purpose of surgery was mostly hygienic. Various methods performed were taken into account [Table - 1]

Adductors of thigh and scissoring interfere with balance, gait and even nursing care. In these types of cases adductors are usually graded as good. But abductors are usually graded as poor in these types of cases due to adduction contracture. Abductor can be assessed in the available range of motion. If after conservative treatment muscle imbalance persists surgery was advised to correct both fixed and hypertonic deformity. Fractional lengthening was performed in 315 cases. The cases which were of rigid variety were undergone anterior obturator neurectomy in addition with fractional lengthening of adductors [Figure - 2]. These procedures are open procedures.

Proximal varus derotation osteotomy was performed in eleven hips which were in subluxation. Thomas test was performed in all cases. Rectus femoris transfer to lateral intermuscular septum is performed if flexion deformity is more than thirty degree with rectus femoris stretch test positive. Other wise iliopsoas fractional lengthening by anterior iliofemoral incision was performed.

Fractional lengthening of hamstrings was just next to tendo achilles lengthening. It has been performed in 358 cases. It has been performed by single transverse or double longitudinal incision [Figure - 3]a,b. Poplitial angle is the indicator for lengthening. Cases taken up for surgery were having popliteal angle more than twenty five degree. Lower advancement of patellar tendon has been done in seven cases is by Baker's modification in which patellar tendon was released from its insertion and fixed with screw within an osteoperiosteal flap. This procedure avoids the risk of growth arrest of proximal tibial epiphysis.

Rectus femoris transfer was done in seven cases having stiff knee gait and Ely's test positive. Equinus deformity was one of the common deformities in children with cerebral palsy. It is frequently associated with varus deformity of the foot. Fractional lengthening of tendo achilles that has been done in three hundred and sixty two cases is the commonly practiced procedure in our series [Figure - 5]. Overactivity of tibialis procedure has been shown to be a cause of varus deformity of foot. For balance of varus foot split transfer of tibialis posterior and split transfer of tibialis anterior with fractional lengthening of tibialis posterior are the practiced procedures. In cases of split transfer of tibialis procedure plantar half is transferred posterior to tibia and attached to peroneus brevis laterally. Combined split transfer of tibialis anterior and fractional lengthening of tibialis posterior has been done in twenty seven cases if varus deformity is present in stance and swing phase of gait cycle.

Grice Green extra articular arthrodesis was performed in nine cases that were young. Foot was stable and having acceptable alignment. Triple arthrodesis of Lambrinudi type was the satisfactory procedure after the age of twelve. Five cases have undergone this procedure.

The patients were always immobilized after operation with toe to groin cast. Stitches were removed after three weeks and replaster done for another three weeks. During post operative period active and passive abduction and adduction, straight leg raising exercises were performed. Patients were asked to stand and walk on plaster after pain relief. Stretching exercises, walking with parallel bar and crutch walking were started once the pop cast is removed.

All the cases were followed up to two years


   Results Top


Three hundred and sixty five limbs were operated in 220 patients. One hundred and forty five patients were having bilateral lower limb involvement and 75 patients with unilateral involvement. Total 1306 procedures were performed.

In cerebral palsy there are many variables which make it difficult to evaluate the results quantitatively. Degree and type of motor involvement, extent of deformity, mental status, motivation, co ordination and balance are the factors influence the post operative results. Ideally the results of surgical treatment should be evaluated on the basis of pre operative and post operative status of the patient [Figure - 5]. So, the results as described by Sidney Keats et al. and Green and Banks et al were analysed

The results were rated as excellent, good, fair and poor according to the criteria proposed by Sidney Keats et al and Green et al[1],[2].

Excellent - No adduction deformity, no scissoring, no flexion deformity of knee joint and no equinus or foot drag, not using any brace.

Good - - lurching gait, unable to walk in full extension and plano valgus type foot.

Fair - - Unable to maintain erect posture, crutch or brace walking, unable to extend the hip and knee and dorsiflex the ankle, genu recurvatum.

Poor - - Unable to walk.

The potential of the patient is very important to assess pre operatively. Muscle power of the limbs assessed gives us an idea about the post operative improvement. It is observed that if dorsiflexor power of ankle is good pre operatively then post operative result is also encouraging.

It has been observed that less is the motor involvement better is the result. This was demonstrated by comparing the pre operative ambulatory status of the patient with that of post operative improvement. There were sixty two percent good results in non ambulatory patients, seventy five percent in supported walkers and ninety five percent in free ambulators. This type of results confirms the importance of pre operative motor status.

Functional result following operative procedures were rated as excellent in ninety eight patients, good in sixty seven patients, fair in thirty five patients and poor in twenty cases. Poor results are due to improper selection of cases. This assessment gives us an idea to select cases which will give us excellent and good results. We have achieved a stage in which we can be able to predict the result in specific cases which will avoid post operative frustration of parents.

Stretching and strengthening exercises by physiotherapist, occupational therapist and handling by parents became easier as the spasticity as well as deformity is reduced post operatively.

Fractional lengthening of adductor site leaves an empty space after skin closure which gives rise to wound haematoma.

Urine contact to the site is there especially in girls. Drain application and two to three times dressing change reduces the chance of infection. Surgery was well tolerated. There were no operative complications. There was mild wound complication in seven cases leading to delayed wound healing.

On examination there was improved in range of movement of hip, knee and ankle. Tendo achilis contracture was completely corrected. In hemiplegics the operated limb was compared with affected limb post operatively rather than normal limb. Results are always excellent to good in patients having age group less than ten. Joint alignment is less than normal if age and deformity are more. In immediate post operative period patients having flexion deformity of knee present with hyperextension deformity. It takes six weeks to six months to align to normal position. Pre and post operative quadriceps exercise helps to align it.


   Discussion Top


Patients with spastic diplegia can walk if they have trunk balance, but the deformities of hip, knee and ankle compromise the efficiency of gait Contracture of muscles to hold the body erect places more stress on joints leading to joint pain. Hip deformities may progress to painful dislocation which affects hygiene and the ability to sit[8],[9],[10],[11],[12],[13]. In patients having a fixed contracture that prohibits abduction more than thirty degree adductor release is to be considered. Obturator neurectomy is to be considered in patients having fixed contracture with subluxation of hip. Rectus femoris transfer to lateral intermuscular septum is performed if flexion deformity is more than thirty degree with rectus femoris stretch test positive. Otherwise iliopsoas fractional lengthening by anterior iliofemoral incision was performed. These surgical procedures are undertaken after taking sufficient period of physiotherapy and occupational therapy.

Four hundred and twenty four procedures performed for adduction contracture of hip on patients. Out of these 315 were fractional lengthening of adductors and ninety eight were obturator neurectomy.These procedures correct the scissoring gait. If the patient is intelligent enough it was possible to increase the strength of abductors to control the hip and prevent waddling type gait. Posterior branch of obturator nerve is not severed to protect some power. Fractional lengthening of adductor magnus may be performed depending on the contracture. Limb is kept in wide abduction and strengthening of abductors in supine and against gravity continues till reciprocal relationship between adductors and abductors is achieved.

Flexion deformity of hip causes lumbar lordosis during standing. Bleck [14] has analysed the hips found in his series. Flexion deformity of hip associated with flexion of knee, hyperextension of knee or normal knee. We have not come across a case having normal knee. Fractional lengthening of iliopsoas is the procedure of choice in the hip joint associated with fractional lengthening of hamstrings or rectus femoris transfer depending on the deformity of knee. It decreases the lumbar lordosis. This procedure is undertaken when flexion deformity of hip is more than thirty degree by Thomas test.

Flexion deformity of knee joint in cerebral palsy may result of various deforming factors. It caused by over active knee flexors and weak knee extensor. Poplitial angle helps us in assessing the deforming force in knee flexors. It has been observed that popliteal angle less than fifteen degree can be balanced by stretching of hamstrings and strengthening of quadriceps. Relief of flexion contracture is not complete unless there is full active extension of knee. In cerebral palsy either quadriceps is weak or it is weak due to over stretching of quadriceps and patellar tendon. Quadriceps exercise is very important to balance the knee. Post operative hyperextension of knee due to fractional lengthening of hamstrings needs vigorous quadriceps exercise to balance the knee joint. Lower advancing the insertion of patella obtain active extension of knee.

Varus, equinovarus and valgus deformity of the foot are some of the common deformities encountered in cerebral palsy. Tendo achilis fractional lengthening is an established procedure. It has been modified by Vulpius, Strayer etc. Well established procedures have been described for aligning the foot by tendon transfers [5],[6],[7],[15]. Over activity of tibialis posterior has shown to be the cause of varus deformity. Split transfer of tibialis posterior to peroneus brevis balances the foot and prevents fixed skeletal deformity. We have done split transfer of tibialis posterior in thirty five cases with encouraging results. Fractional lengthening of tibialis posterior and split transfer of anterior has been performed in cases having varus deformity in stance and swing phase of gait cycle. Taught ness of tibialis anterior indicates its transfer also.

Grice subtalar extraarticular arthrodesis has been done in nine cases. It should be attempted in young patients having valgus deformity. Results are also encouraging. Feets operated by Baker [15] below three years showed no growth disturbance. Our youngest patient was five years old.

It is also important that the patient has a mental status adequate for training. [16] The results of surgery is good to excellent in patients having IQ sixty onwards. Poor results explained by poor IQ and poor motor function and inadequate co operation from family. Excellent to good results obtained from enough motor function and control.

Cerebral palsy is now the most common orthopedic problem of child hood. Orthopedic surgery has a worth while contribution towards the treatment of cerebral palsy. When these cases are selected with care appropriate surgical procedures are performed in time and patients are adequately supervised, the benefits of surgery of limb alignment are greater than those provided by any other modalities of treatment and are achieved quickly. A severely motor involved child without inner urge of improvement will not benefit from surgical measures. We should recognize these facts and direct our attention to the needs of children. Even little improvement may be just enough to allow a child to walk with or without support and make his care less cumbersome

 
   References Top

1.Banks HH, Green WT. Adductor myotomy and obturator neurectomy for the correction of adduction contracture of the hip in cerebral palsy. J Bone Joint Surg (Am).1960; 42: 111-126.  Back to cited text no. 1    
2. Keats S et al. An evaluation of surgery for the correction of knee flexion contracture in children with cerebral spastic paralysis. J Bone Joint Surg (Am).1962; 44: 1146-1154.  Back to cited text no. 2    
3. Roosth HP. Flexion deformity of the hip and knee in spastic cerebral palsy treatment by early release of spastic hip flexor muscles J Bone Joint Surg (Am). 1971;53: 1489-1510.  Back to cited text no. 3    
4. Root L et al. Posterior tibial tendon transfer in patients with cerebral palsy ; J Bone Joint Surg (Am).,1987;69: 1133-1139.  Back to cited text no. 4    
5. Green NE, Griffin PP, Shiari R. Split posterior tibial tendon transfer in spastic cerebral palsy; J Bone Joint Surg (Am).1983; 65: 748-759.  Back to cited text no. 5    
6. King TF. Split posterior tibial tendon transfer in children with cerebral spastic paralysis and equinovarus deformity. J Bone Joint Surg (Am). 1985; 67: 186-194.  Back to cited text no. 6    
7. Barnes MJ, Herring JA. Combined split anterior tibial tendon transfer and intra muscular lengthening of the posterior tibial tendon. J Bone Joint Surg (Am).1991; 73:734-738.  Back to cited text no. 7    
8. Pollock GA. Surgical treatment of cerebral palsy. J Bone Joint Surg (Br).1962; 44 : 68-81.  Back to cited text no. 8    
9. Cooke PH, Cole WG, Carey RP. Dislocation of in cerebral palsy. J Bone Joint Surg (Br).1989; 71: 441-446.  Back to cited text no. 9    
10. Howard CB, McKibbil B, Williams LA, Mackie I. Factors affecting the incidence of hip dislocation in cerebral palsy. J Bone Joint Surg (Br).1985; 67: 530-532.  Back to cited text no. 10    
11. Hoffer M. Management of hip in cerebral palsy. J Bone Joint Surg (Am).1986; 68: 629-631.  Back to cited text no. 11    
12. Root L, Gross JR, Mendes J. The treatment of painful hip by THR or hip arthrodesis. J Bone Joint Surg (Am).1986; 68: 590-598.  Back to cited text no. 12    
13. Editorial. Hip flexion deformity in spastic CP. J Bone Joint Surg (Am).1971; 53: 1465-1467.  Back to cited text no. 13    
14. Bleck EE. Postural and gait abnormality caused by hip flexion deformity in spastic cerebral palsy. J Bone Joint Surg (Am).1971; 53: 1468-1488.  Back to cited text no. 14    
15. Baker LD, Hill LM. Foot alignment in the cerebral palsy patient. J Bone Joint Surg (Am). 1964; 46: 1-15.  Back to cited text no. 15    
16. Das SP. Management of upper limb in cerebral palsy. Ind J Physical Med Rehab. 2002; 13: 15-18.  Back to cited text no. 16    

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Correspondence Address:
S P Das
SVNIRTAR. Olatpur, Bairoi, Cuttack- 754010. Orissa
India
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