Thanks. So thanks Michelle and Michelle for taking the harder ones. And so I was asked to talk about specific surgical techniques and I'm going to kind of focus that on the blue plate special as well and Scott I'll have to get that little blue plate picture from you because I don't think we have that up in Minnesota. But the three main surgical tools that we all have as far as treating these kind of muscle and movement disorders fall into kind of three basic categories. The first category would be soft tissue releases and this generally has to do with lengthening of tendons or muscle or sliding the muscle origin. When you do a proximal carpectomy and you shorten the skeleton that effectively lengthens the tendons or muscles as well. So again if a muscle is contracted, shortened, spastic, one option is soft tissue releases. The second surgical tool we have in our toolbox is tendon transfers and again these are to augment the antagonist movement. So not just lengthening the flexors but augmenting the extensors. And then the third category is some sort of bone or joint stabilization. And the most common are the MCP joint or the wrist joint. And usually in the younger children we tend to do the capsulodeses particularly MCP joint. And in the older children we tend to do the fusion. And in the skeletally mature and really the spastic quadriplegic is the most common for the wrist fusion. And that's not so much the focus of my talk today. So I was going to focus on the most common disorders. And again these come in all different varieties. So these need to be tailored to the specifics of the individual who you are treating. But we see this very common muscle firing pattern in the upper extremity as a result of the central nervous system disorder. And the most common pattern we see is that elbow flexion, forearm pronation, wrist flexion, ulnar deviation, thumb and palm and then either swan neck or flexion deformities of the fingers. So if we're looking at what the most common procedures are, for the elbow flexion deformity it would be a release or lengthening of the affected muscles which would be the biceps and the brachialis. And sometimes in the more severe the brachioradialis off its origin as well. For the forearm pronation the most common is the pronator teres release. But again other options would include pronator teres rerouting particularly if you had good phasic control of your pronator teres muscle. In wrist flexion again you can do soft tissue releases such as flexor pronator slide. The most common for lack of active wrist extension would be the FCU transfer. And then for the thumb and palm again this gets a little more individualized but the blue plate special would be a release of the tight muscles which most commonly would be the thumb adductor and maybe FPV. Augmenting the lack of extension or abduction with an EPL rerouting and then if necessary a stabilization of the joint. So let's just run through those each one at a time in a little bit more detail. So the elbow flexion deformity again we treat these with a lengthening of the affected muscles. I am not an advocate of doing capsular releases. That would be particularly with the quadriplegic with a very severe elbow flexion contracture where you might consider that. And the problem is the neurovascular bundle ends up being your limiting factor more so than your capsule. And many of these kids are cognitively impaired. And when I was a fellow I saw a compartment syndrome with this which wasn't recognized as a because of the cognitive impairment. So I think that's where you want to just make sure that you first do no harm. So I'm going to use for this blue page special this example of a nine-year-old male. He has a left spastic hemiplegia. He has elbow flexion form pronation, wrist flexion and all the deviation in the thumb and palm deformity. So this is his surgery. His shoulder is at his right. Here is his elbow. His his wrist is at the left. We identify and isolate the biceps tendon. I use a Z lengthening of the biceps tendon trying to go almost fully all the way down to the radial neck insertion and approximately up to the muscular portion. And so we get two limbs the proximal limb coming off the muscular portion and a distal limb with a Z lengthening. When those are then reflected laterally we reflect the radial nerve and medially we reflect the neurovascular bundle with the brachial artery and I'm sorry radial nerve laterally median nerve medially and a fascial release of the brachialis and then a lengthening with a sewing in of the two limbs of the biceps tendon. So that would be the most common surgical procedure that I would do. And I would do these even for a dynamic deformity. So they don't have to have a severe passive range of motion and loss. But a lot of these kids their complaints are when they run. They're functional complaints. They have such severe elbow flexion posturing on that side compared to the contralateral side. And so this is one of the things that kids really like afterwards because they have less asymmetry. The second is the pronator teres release and this is done with a release off the origin to lose the spastic nature. The pronator quadratus can also be released as described by Dr. Michael Tonkin. But if we do a pronator teres release it leaves the pronator quadratus as a pronating muscle. And again this is the medial side of the elbow. This is the lateral and the pronator teres is released off its origin. The radial artery and flexor carpi radialis are reflected medially and the brachial radialis and the radial sensory nerve dorsally. And there's usually a long tendinous insertion of the pronator teres. I think it's important to release that tendinous insertion and the muscle and it's part of the flexor pronator quad. So I try to free it up so you can really pull back and forth on that muscle and make sure that when you cast them in supination it isn't going to just heal back down into its previous position. The next procedure that we would commonly do as multiple simultaneous procedures would be to assess the wrist and if there is not active wrist extension. And again whether that's on demand as Michelle, one of the Michelles, mentioned or whether that's functionally that during tasks and activities they don't extend the wrist. I think we're getting more towards not just in bodily impairment but a functional deficit in wrist extension. And this would be done through a long ulnar-sided incision for a harvesting of the donor tendon. And I like to check the excursion of that muscle. You want to free that muscle up from its fascial origin. It has multiple innervations and taking some of the small branches for distal innervation might help a little bit with the spasticity. But certainly there's plenty of innervations proximally. And you can see here we have three to four centimeters of excursion off of this muscle when you want to get that freed up so that you get good excursion while you transfer it. This was a catabaric study I had done a long time ago looking at the supination effect of the FCU to ECRB transfer. And we did two models. One was where we just released the distal one-third and then the second one we released the distal two-thirds. And if you think about the mechanics of your own arm, if you take that FCU and you wrap it around the ulnar border and you place it in radially, it'll have a supination moment arm. And what we found is that if you release it, the donor muscle through the proximal two-thirds of the forearm, that you get a greater supination effect than if it has more of a right angle and only the distal one- third is freed up. So I try to get a nice straight line of pull for the FCU coming around the ulnar border so that we get some secondary supination effect in addition to the wrist extension effect. I think that ECRB and ECRL are both often adherent to each other. These kids don't have selective control of the two muscles, so I'm not sure that it matters if you transfer it into one or the other or both. They probably are both functioning or not functioning very well together. And that's sewn in place. And then lastly, tensioning. And this is the thing that has changed from the original green transfer. When green originally described it, he described tensioning it in wrist extension. And we found that as kids are in an extensor habitus, that they lose that tenodesis effect with opening of their fingers as their wrist falls into some flexion. So this is him before we placed the tendon transfer. And we want to place that so that with gravity, we sit with the wrist in neutral position. Lastly, the thumb. And again, I think that this is probably the most difficult. And we want to release the tight structures and augment the weak structures. And part of that is trying to assess what's tight and what's weak. Dr. Manske showed that as the EPL comes dorsally around the Lister's tubercle, it is a thumb extensor and a secondary AD ductor. And if we bring that down and into the first compartment, it is a thumb extensor and a secondary AB ductor of the ray. And so this is a different case actually, because I think it illustrates it better, where you can see where the entire thumb ray is AD ducted. And even when they're asleep and they're placed in a hand holder, that metacarpal ray is AD ducted across the palm of the hand. And so we get some secondary AB duction. So the release would be through a metav type procedure through the palm of the hand. And again, releasing what's tight. In this particular case, I did the transverse endoblake heads of the AD ductor, but did not release the flexor brevis, as that was not a deforming force in this case. And then we want to augment the weak structures. So again, our EPL tendon is routed through our first dorsal compartment. In this particular case, because it was mostly metacarpal AD duction, this was woven into place onto the first metacarpal instead of more distally, because we do not want to augment the MP hyperextension deformity. And again, this is tension so that when we pull on the EPL tendon, it pulls the thumb ray out of the palm. And in this particular case, I did pin it, because at rest it would have a tendency through the CMC joint to sit with that ray AD ducted. And we want it to heal at rest with that AD ductor in a lengthened position. Generally, these kids are treated one month in a cast. The second month, they're in a removable brace and start active range of motion. The third month, they wear the brace only at night and start full active ADL function. So again, I want to just say that the results of these, I think there have been a variety of different results. We do have a paper on Saturday morning with a multi-center surgical randomized study through the Shriners Hospital system looking at surgery versus Botox or ongoing therapy. Thank you very much.

surgical techniques

muscle and movement disorders

soft tissue releases

tendon transfers

bone or joint stabilization