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Surgical treatment of spastic hemiparesis

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Objectives

Surgery aims to be a definitive treatment.

The objectives are to improve the position of a limb and its function. Improved position also determines an improvement in the aesthetics of the patient.

The surgery has to be multilevel, that is, at all levels of the limb, in order to improve all the problems in a single surgery (elbow, forearm, wrist, etc).


Age

The ideal age range to start surgical treatment is 6-8 years


Surgical Techniques

Given the heterogeneity of patients, it is not possible to recommend a single general treatment.

Improve elbow extension
Improves the scope of the patient's limb. It also improves the aesthetic appearance, as the bending of the elbow is striking while walking. Technique: extend the elbow flexor muscles (Figure 10).
 

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Figure 10. Patient with elbow extension deficit. Selection of one of the elbow flexor muscles for sectioning and enhancing the extension (stretching the elbow).


Improving supination
On a day to day, pronation (palm facing down) is more important than supination since most of daily living activities are performed with the hands pronated (eg computer keyboard use). The improvement in supination facilitates activities such as washing your face or carrying a tray. Technique: lengthening pronator muscles or modification of its route to transform them into supinators ("pronator rerouting") (Figure 11).
 

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Figure 11. Patient with a supination (turning the palm upward) deficit due to cerebral palsy with right hemiparesis. Improvement in supination after pronator muscle lengthening.Mejora extensión de la muñeca


La extensión de la muñeca es necesaria para una mejor adquisición de los objetos (pues la mano caída se interpone entra la visión y el objeto) y mayor fuerza de agarre.
Técnica: Alargar la musculatura flexora o transferir músculos flexores a los extensores (transferencia muscular) (Figura 12 ).
 

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Figure 12. Patient with a wrist extension deficit. A tendon transfer is performed, to give more force to the extension and improve grip strength.


Improving separation of the thumb
The separation of the thumb is essential for manipulating objects between the fingers and thumb. Technique: lengthening of muscles in the palm or change of the route of muscles, to make them work as spacers (rerouting) (Figure 13).
 

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Figure 13. Patient with difficulty in separating the thumb. A lengthening of the muscles of the thumb (top-right) and a tendon rerouting (below) are performed.


Results
The most complicated issue in patients with CP is the choice of surgical approach. This is due to the clinical heterogeneity of these patients. The strategy should be individualized. Patients should be assessed multiple times before making a decision. With proper patient selection, we can improve the hand function and ability to perform activities of daily living. Furthermore, an improvement in the position of the extremity will result in an aesthetical improvement and an increased self-esteem (Figure 14).


 CMI 

Figure 14. Image showing "before and after" the surgery and occupational therapy. Improvement in hand function with increased ability to perform daily living activities such as using cutlery, cutting or tying shoelaces.

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