Brought in where deformity is present or develops and impairs function, for example in contractures. Gait analysis (q.v.) can be used to determine what surgery is needed. There is sometimes a need for successive surgeries as a child grows, and/or as contractures develop. Orthopaedic surgeons work with physiotherapists and orthotists (q.v.) to put physical programmes, orthoses and prostheses in place, and do not necessarily use surgery.
Arthrodesis
Fuses bones together to reduce the tendency of a spastic muscle to pull the joint into an abnormal position and cause pain. Usually used for the ankle and foot, sometimes the hip. Vertebral arthrodesis is used for scoliosis (curvature of the spine). An orthosis is sometimes fitted for spinal stabilization, to improve posture, with or without surgery.
Contracture release
The tendon of a contracted muscle is cut either partially or completely. The joint is then positioned at a more normal angle, and a cast is applied. Re-growth of the tendon to this new length occurs over several weeks. Serial casting may be used to extend the joint gradually. Physical therapy is used to strengthen the muscles and improve range of motion. There are ages when surgeons consider it best to perform these operations, because of the stages of children’s movement development.
Scissor walking can be caused by spasticity in the adductor muscles in the upper leg. Adduction release surgery, commonly performed between two and four years of age, can help to relieve this.
If the hamstrings (behind the knee, one on each side) need lengthening, this is often done between seven and eight years of age. Sometimes distal rectus femoris transfer is done with it, to try to improve movement of the knee.
If the Achilles tendon (behind the ankle) needs lengthening, this again is often done between seven and eight years of age. It is the most common site for contracture release. The tendon is lengthened to correct "equinus" deformity, in which the calf muscles pull the foot downward to point the toes. Gastrocnemius recession is surgery to relieve tightness in the calves.
There is an operation called Proximal rectus (femoris) release, to try to normalise the hip movement, however research so far has suggested it is less successful.
Contracture release is also used for shoulders, elbows, and wrists.
Osteotomy
Removes a small wedge from a bone to realign it. A cast is applied to keep it in position while it heals. Usually used for hips and feet, where there has been too much rotation.
Selective dorsal (root) rhizotomy/functional dorsal rhizotomy/SDR/selective posterior rhizotomy/posterior rootlet rhizotomy
Cuts overactive nerves at the base of the spinal column, in cases of severe spasticity and/or chronic pain. Occasional complications include paralysis and sensory loss, infection, leakage of spinal fluid, or temporary abnormal sensitivity of the skin on the feet and legs, and change in bladder control. It causes less muscle weakness than contracture release, and may reduce the need for such operations later. The removal of all or part of a nerve is called Neurectomy.
NICE guidance on Selective dorsal rhizotomy, Nov. 2006, is available at http://guidance.nice.org.uk/IPG195, or tel: 0870 155 5455 quoting reference IPG195.
Tendon transfer
Changes the attachment point of a spastic muscle so that it can no longer pull the joint into a deformed position, or to improve movement. Used for many parts of the body. Splinting or casting follows surgery, then it is necessary to learn how to make the right movements with the tendon in the new position.
Tenotomy to prevent hip dislocation
Surgery on tendons to improve the function and position of spastic hips, for some children.
National Institutes of Health, Cerebral Palsy: Hope through research [surgery section]. www.ninds.nih.gov
Bunata RE. Pronator teres rerouting in children with cerebral palsy. Journal of Hand Surgery [Am]. 2006 Mar;31(3):474-82. [forearm tendon transfer]
Kay, RM et al. Outcome of gastrocnemius recession and tendo-achilles lengthening in ambulatory children with cerebral palsy.Journal of Pediatric Orthopaedics B.13(2):92-98, March 2004.
Schaefer MK et al. Effects of early weight bearing on the functional recovery of ambulatory children with cerebral palsy after bilateral proximal femoral osteotomy. Journal of Pediatric Orthopaedics 2007 Sep;27(6):668-70.
McMulkin ML et al. Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy.
Journal of Pediatric Orthopaedics 2005 Jan-Feb;25(1):74-8.
Presedo A et al. Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. Journal of Bone and Joint Surgery 2005 Apr;87(4):832-41.
