Good morning. I'm going to talk about surgical indications and planning, and I will segue from what Michelle just talked to you about and into what Anne's going to talk to you about. I do want to point out, though, that as you could tell from Michelle's talk, these kids take a lot of time and energy, your time and energy, to figure out what's going on and figure out what the best thing to do for them is. I learned early on from one of my mentors that there's three stages of understanding cerebral palsy. The first stage is when you just start seeing kids with this condition and realize you don't know anything about CP. The second stage, you think, you know, you're starting to understand it, you think you know what to do. And the third stage, the most advanced stage, is when you realize you don't know anything about CP. So the definition of CP was actually revised about six years ago, and I think this is a big improvement in previous definitions because it incorporates the concept of activity limitation, which I'll come back to. But if you look at the World Health Organization hierarchy of function, activity is, I think, what a higher level than we're usually trying to address, and I'm going to come back to that because it's one of the major points of my talk. As Michelle indicated, the types most amenable to treatment are hemiplegia and then of the different types of tone, spasticity. And the deformities in CP are familiar to you, I'm sure. Elbow flexion, forearm pronation, wrist flexion and ulnar deviation, thumb and palm, and then swan neck and the PIP joints, variably. And we're often trying to address all of these with, as Scott said, a blue plate special, a different combination of surgery. So as I mentioned, the World Health Organization has created and promulgated the concept of a hierarchy of function. And as orthopedists working with our therapy colleagues, we tend to focus on impairment measures. These are quick and easy. They're reproducible. They don't mean nearly as much to our patients as does the next level and probably even the third and fourth levels. And activity measures, as Michelle indicated, some of the tests we use are the way that a patient executes a task. And the limitations in activity are what we call disability. Participation measures, I think, are something we really strive for to help kids do the things that are important to them in life, not just buttoning their pants or putting their socks on but things that are important to them. And then finally, quality of life, purely subjective. Does anything we do actually improve the quality of life from the kid's point of view? And this is something to strive for. I don't think we're even close to being able to, hopefully we do this in some instances, but being able to measure this very well. So the surgical indications for these conditions, as I mentioned, we're going to address the elbow, forearm, wrist, thumb, and fingers. And this picture is just to remind me how important our OT and hand therapist colleagues are in this endeavor. And physical therapists also. A lot of what we do, they make look good later on. So as I mentioned, the classic indications, impairment measures, these are the indications we use for surgery. And I'll go through them. And this is what's in the literature. And it's what we all learn. I would argue, though, that these are not as important as some of the other measures, some of the things that Michelle mentioned. Active range of motion, passive range of motion, and strength. Easy to measure, probably reproducible in different people's hands. And looking at each of the levels that I mentioned, lack of elbow extension. So a passive and active range of motion measure has been traditionally the indication for anterior elbow release. And it's not that that's not a good measure. It's a good way of measuring how well we did the operation from our point of view. Mansky talked about that in 2001. And all of the articles I mentioned here are in the reference list at the end of the handout. Lack of supination, the classic indication for this is, the classic indication for pronator teres tenotomy is lack of supination. Strecker and also Mansky looked at pronator teres tenotomy versus rerouting. And probably there's not a lot of difference. I would agree that doing a rerouting or basically any tendon transfer in somebody with a hint of dystonia or apoptosis is a bad idea. I'm more comfortable with the tenotomy. Surgical indication for green transfer, FCU to extensor carpi radialis brevis, is again an impairment measure, wrist flexion and ulnar deviation deformity. Here you also want to make sure that they're able to open their fingers when you place them in the position that you're hoping to achieve with your wrist transfer. And then for the thumb, the classic indications are thumb flexion and adduction, another impairment measure. And here the operations, as you'll hear in Anne's presentation, are adductor pollicis release and EPL rerouting, also described by Mansky, whose name you see come up again and again when we talk about CP. Finally, the swan neck deformities, these are a little tricky. And when you're looking to do a blue plate special and address the elbow, the forearm, the wrist, the thumb, those operations all work very well together. But as Dr. Tonkin and Dr. Van Heest described, the lateral band rerouting does not work as well when combined with those other procedures, because often changing the wrist position will change the tension on the flexors and make the swan necks possibly worse. So I hold off on that and do that as a separate operation if they need it. So when we're planning surgery for these kids, I think it's very important up front to assess the family's commitment. This is extremely difficult, because people tend to appear more committed, perhaps, than they are. They don't really know what they're getting into. But therapy post-op is very important. And so you want to make sure that they're going to be able to get therapy post-op. This will differ from state to state. In some states, there's a children's services that provide services for these kids on a county basis. At least that's how it works in California. Some states don't have as good services. So doing these operations on kids who aren't able to get therapy afterwards, I think, is probably not a good idea. Combine the procedures as needed or as needed by the child. And coordinate the therapy protocols. There's individual protocols for each of these procedures. Some of the other items to take into account when surgical planning are age. Dutch talked about this in a 2010 article. And possibly, when we do wrist transfers too early, we can cause later deformities with growth. Cognition. We have a cognition test we use. I haven't found that to be a contraindication. But it's good to be aware of beforehand how well the kid is going to understand the therapy program. And these kids are often in therapy when they come to see you. And the therapist has a good idea of their cognition. Ann Van Heest has talked about stereognosis. I agree that this is a very important prognostic factor, but not a contraindication. I think even improving the position with the poor stereognosis is worthwhile, although I don't think it changes with surgery. And Ann will be able to talk more about that. We follow the basic principles of tendon transfers. You have to have an expendable donor. It has to have the length and excursion required to do the job that you want it to do. Just the basic principles. And really, we look for isolated control. Kids with CP have abnormal neuroplasticity. So whereas you can do a tendon transfer in a kid with brachial plexus palsy or some other condition and expect it to change phase, I don't think this works as well in these kids. And we do use dynamic EMGs for this to test what the phase of the FCU is, for instance, before we transfer it. This is an off-label use of Botox. But it can be used to preview the effects of surgery. Ann Van Heest and I have just completed, with the help of several other people in this audience, a randomized study of the outcomes of botulinum toxin versus surgery. I'm not going to tell you the results, because she's presenting them on Saturday. But I have found, after using botulinum toxin fairly extensively over several years, I found that it's not as useful as it initially promised to be. And I've been disappointed in it. I think it's also useful. I mean, in pediatric orthopedics, we always look much more intelligent if we prepare the family for what's likely to happen down the line. Pediatricians do this, too. So if we tell the family, when the kid's little, that they may need more surgery when they're teenagers, it looks like we were thinking ahead. If we surprise them with that later on, it looks like we didn't have our act together. So I think talking early about the possibility of stabilizing the wrist and possibly the thumb MP, I think that's probably one of the more useful things we do later on. And I would just mention it here as something to lay the groundwork for when the child's older. So I guess, in summary, I would say that most of our assessments are impairment-based. I think I'd like to see us turn towards focusing on activity-based assessments. As Michelle mentioned, the SHU, I think, is one of the better planning assessments. Blocks and blocks is also a very nice one. It's quick and easy. Participation measures aren't there yet. The CAPE is the only one that's out there that I know of, and it's not... Well, the Canadian Occupational Performance Measure 2. The CAPE is not as good as I thought it was going to be when I started using it. And then quality of life. We don't want to forget about that, because that's really the bottom line. Thank you very much.

surgical indications

cerebral palsy

activity limitation

types of CP

comprehensive approach