Early Motion Regimen Following Surgical Treatment of Cerebral Palsy Affecting The Upper Extremity. The Leeds Protocol Mr J Wiper 1, Mr K G Chan 2, Mr W Saeed 1, Mrs J Burdon 1, Miss M Dolan 1 1 St James’s University Hospital, Leeds, United Kingdom 2 RIPAS Hospital, BSB, Brunei Summary The Leeds Cerebral Palsy Clinic over a 5.5 year period provides surgical treatment through specialist multidisciplinary team approach to 46 patients, the majority suffering from cerebral palsy. These patients underwent surgical treatment of elbow, wrist, finger and thumb contractures and deformities. All transfers with the exception of biceps lengthening were started on an early motion protocol on the first postoperative day. Out of 110 transfers in 46 patients there was one case of tendon rupture remote from the site of tenorraphy as a result of non-compliance. Early mobilisation did not result in permanent complications and is safe for the procedures used in this series. Introduction Post operative therapy is vital to the successful outcome of reconstructive surgery to the musculoskeletal system. In the Leeds Cerebral Palsy Clinic, surgical treatment to the upper limb deformity is provided through specialist multidisciplinary approach and the whole process is summarised below: Method and Material Prospective review of all procedures carried out by the senior author for the treatment of upper extremity deformities. Results 47 patients, 121 transfers. 2 pronator teres re-routing immobilised as stand-alone procedures excluded. One patient, 2 separate surgical procedures (30/06/99 & 14/08/00), 4 transfers (FCU to EPL, PL to EPB, FDS3 to EDC, FDS4 to ECRB) immobilized post op (? prior to start of Mr Saeed’s practice) and excluded, 4 transfers (2 transfers each in 2 patients) were redo of the same transfers and excluded. 46 patients, 111 transfers, 13 complications (8 patients) (Table 1) Most common complication is a sequalae of FDS harvest which is swan neck deformity in the respective finger One rupture of EDC following FDS4 to EDC transfer with matev weave of EDC one month following surgery References 1.Krotoski & Tomancik (1987) The repeatability of testing with Semmes- Weinstein monofilaments. The Journal of Hand Surgery Vol 12A. No. 1: Dellon (1981) Evaluation of sensibility and re-education of sensation in the hand. Williams & Wilkins. Baltimore. 3.House et al (1981) A dynamic approach to the thumb in palm deformity in cerebral palsy. The Journal of Bone and Joint Surgery Vol. 63 – A, No. 2:216 – Pinzur M.S. (1991) Flexor origin release and functional prehension in adult spastic hand deformity. The journal of Hand Surgery Vol. 16B. No.2: Germann G. (2001) Early dynamic motion versus postoperative immobilisation in patients with extensor indicis propius transfer to restore thumb extension: A prospective randomised study. The Journal of Hand Surgery Vol 26A. No. 6:1111 – Brüner S. (2003) Dynamic splinting after extensor tendon repair in zones V to VII. Journal of Hand Surgery. Vol 28B No. 3:224-7 Discussion Early mobilisation in our series resulted in only one post op rupture in our series. The patient is a male adult with mild severity of cerebral palsy who has good power and moderate voluntary control prior to surgery. This low incidence may be attributed to: 1. CP as a group has weaker muscles and poorer motor control 2. Pulvertaft tendon weave is strong and no rupture was reported in a series of 10 patients undergoing extensor indicis propius tranfer for thumb extension with early dynamic motion 5 3. Simultaneous release of flexors (weakened extrinsic flexion force) and transferred flexors to power extensors (weakened intrinsic flexion), likely to result in synergistic weakening of forces acting to disrupt the tendon weave. Advantages of early mobilisation following tendon repair are well validated 5,6 and our patients also benefit from: 1.Earlier commencement of rehabilitation and relearning of new function thus shortening of rehabilitation time 2. Reduce potential risk of tendon adhesions to surrounding tissues and hence reduce need of tenolysis Follow up as per individual needs Farication of Thermoplastic splint Leeds protocol for early motion post tendon transfer performed at the wrist, fingers or thumb: 1st day Post Op Commence passive/active exercises Wrist extension / flexion Digit extension / flexion concentrating on MCP joints +/- Thumb 1st Web Stretches Opposition to neutral Inpatient Discharge Decided by MDT, dependent on: Pain Control Wound condition Pt / parent or carer independent with splint and exercise regime Compliance Distance from home to hospital Splint modifications when required (usually removed by six weeks post op) Physio weekly (up to 3 times per week) as assessed by therapist Full functional assessment at one year post op Post op Therapy Aims Gain maximum compliance from patient / parent or carer Maintain full passive range of movement as achieved in theatre Initiate normal movement patterns Pre Op Therapy Aims  Identification of patient expectation  Awareness of psychosocial needs  Assessment of current functional ability Full functional assessment to include: Summary of functional abilities including: social/work/education/hobbies Patient goals including hygiene/cosmetic/function Resting position of arm/hand Active ROM/ability to hold when placed passively into a position Sensation 1 Stereognosis Grip/pinch Dexterity 2 Pattern of hand use Validated grading systems used: Hand placement 4 Thumb in palm deformity 3 Volunatary Motor Capacity 4 Clinic consultation with patient / parent / consultant / therapist to plan future management O.T Pre Op assessment carried out Assess for provision of splint Prioritised referral from consultant for Pre Op assessment Inclusion Criteria Primary operations consisting of all kinds of tendon transfers and re-routing of Pronator Teres tendon Exclusion Criteria Patients who has contractures as a result of cerebrovascular stroke are excluded Patients who did not undergo early mobilisation following surgery for whatever reason Conclusion Early mobilisation is safe for procedures and in this group is not associated with high rupture rate or permanent complication. ProcedureNumberComplication Pronator Teres Re-routing18 FDS3 to EDC21 2 swan neck, 1* over correction with wrist in fixed extension of 60 degrees, 1 redo ? Why FCR to ECRB171 over correction, 1 weak post op due to poor physio compliance FCU to ECRB12 1* over correction with wrist in fixed extension of 60 degrees, 1 redo ? Why FDS4 to EDC81 adhesion with poor pull through, 1 rupture of tendon FDS3 to ECRB5 FDS4 to ECRB31 swan neck FDS2 to ECRL2 FDS3 to ECRL2 FDS3 to opponens plasty2 FDS4 to EPL2 PL to EPB1 ECRL to ECU1 ECU to ECRL1 FCR to EDC1 FCU to ECRL&B1 FCU to ECRL1 FDS2 to APL1Re route ? Why FDS3 to ECRL&B1 FDS3 to FPL1 FDS4 to EI & EDC1 FDS4 to EPB1 FDS4&5 to APL1 FDS5 to EPB1Re route ? Why FDS2 to ECRL&B11 swan neck FDS2 to EDC1 FDS4 to APL1 Pl to APL1 PL to EPL, EPB & APL