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Single Event Multilevel Surgery In the Spastic Cerebral Palsy Upper Extremity. A Review of the Expanded Green Transfer

Saturday, October 20, 2012: 9:07 AM
Melrose (Hilton Riverside)
Melia D. Hernandez1, John A. Ruder1, Julie Gaby, MPA, OTR/L, ATP2 and Jonathan H. Phillips, M.D.3, (1)University of Central Florida College of Medicine, Orlando, FL, (2)Pediatric Rehabilitation, Arnold Palmer Hospital for Children, Orlando, FL, (3)Pediatric Orthopaedics, Orlando Health, Orlando, FL

Introduction: Cerebral Palsy is characterized by static, upper motor neuron weakness following central nervous system injury in the developmental period. In the spastic form, the upper extremity is most often positioned in elbow flexion, forearm pronation, wrist flexion and ulnar deviation. Green described a procedure involving transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis or extensor carpi radialis longus to correct wrist palmar flexion and ulnar deviation. Green proposed strict preoperative criteria to predict surgical success.

Purpose: To determine if a single event multi-level surgery including the Green Transfer provides benefit to the patient when not adhering to Green’s criteria to operate.

Methods: A retrospective study of patient charts, OT evaluations, and operative reports for 46 patients who underwent the Green transfer at our institution from 1997-2011 were reviewed.  A single surgeon was the source of all patient data. A sub group of ten patients had pre and post-operative OT evaluations. Mean age at surgery was 10.4 (range 6 to 15). No patients had previous surgery of the upper extremity. Nine were hemiplegic with 1 quadriplegic. Functional status was determined using the Green and Banks rating scale as modified by Samilson and Morris as well as cosmesis, functional skills, and environmental usage. A novel set of criteria assessed functional variety, frequency of use, and efficiency of care.

Results: There were a total of 111 procedures in addition to the Green Transfer. Three patients needed revision surgery. Six patients needed additional surgery. Using the Green and Banks rating scale, pre-operatively there were 4 poor, 4 fair, 2 good and no excellent. Post-operatively there were 1 poor, 6 fair, 3 good and no excellent. Cosmesis improved an average of 2.4 points with all patients showing improvement. Functional skills improved an average of 0.8 points with 6 showing some improvement, 3 showing no improvement. Environmental usage improved an average of 0.1. One patient showed improvement, 8 showed none. Functional variety improved an average of 0.3 points, frequency of use improved an average of 0.5 points, and efficiency of care improved an average of 0.3 points.

Conclusion: Cerebral Palsy is a debilitating disease causing severe impairment in daily functioning. The Green Transfer as part of a multi-level surgical approach in the spastic upper extremity provides an opportunity to improve position, cosmesis, and functional use of the involved limb. This study found improvement in patients who did not meet the Green criteria for surgery. In absence of fulfillment of Green’s criteria patient’s quality of life can still improve with improved cosmesis and functional skills. More liberal patient selection criteria are warranted.