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Orthopaedic procedures for cerebral palsy fact sheet

Orthopaedic procedures for children with cerebral palsy

Bony procedures

Femoral Varising Derotation Osteotomy

This is a bony procedure which will reposition the head of the femur (ball) in the acetabulum (socket). It is used for correction of hip dysplasia or dislocation and can also be used to rotate femur so the knee points forward.

The child will be non-weight bearing for 6 weeks. Post-operative positioning involves keeping legs apart and taking care to keep the hips in neutral rotation i.e. knee caps pointing up. A plaster cast can be used to provide support.

Femoral Derotation Osteotomy

This is used to rotate the femur so the knee points forward. The femur is rotated just below the hip and fixed with a plate. The child is typically non-weight bearing for 6 weeks, though this may be different for each child. A cast or leg bands may be used. Care must be taken to keep the hips in neutral rotation, i.e. knee caps pointing up.

Distal Femoral Extension Osteotomy

This is used to straighten the knee. The thigh bone is cut and re-angled just above the knee. The exact method may vary for each child. The child will be non-weight bearing for 6 weeks. A long leg cast or knee brace may be used to maintain the correct position. As the knees are straight, a chair with a raised leg support should be used and may need to be hired.

Try to keep the knee caps pointing up. This helps the muscles behind the knee stretch. Lots of sitting upright with knees straight and legs apart is important.

Tibial Derotation Osteotomy (Supramalleolar Osteotomy)

This is used to rotate foot either in or out. The shin bone is rotated and fixed in place. A below-knee cast is used. The child will typically be non-weight bearing for six weeks. Elevation is important as foot swelling may require alterations or removal of the cast which compromise the cast’s ability to maintain the correct position.

Os Calcis Osteotomy / Lateral Column Lengthening

This is used to turn the foot in. It is used when the foot is flat and turns out. The child will be non-weight bearing for 6 weeks.

As a bone graft is used, standing and walking should only be done after clearance from the orthopaedic consultant. Standing will require protection from a cast or AFO.

Weight bearing using a synthetic graft must be protected for 12 months as it is at risk of being damaged before the child’s bone has grown through it and remodelled.

Soft tissue procedures

Psoas lengthening

The muscle at the front of the hip is called psoas. It attaches to the front of the lumbar spine. Tightness and spasticity in this muscle will cause the hip to flex. In standing and walking it causes the child to lean forward and the bottom to stick out. Sometimes this effect is hidden when the knee is flexed during standing and walking but is exposed when the knees are straightened.

Following surgery, the child will be required to lie prone as often as possible. Typically this is twice a day for 1 hour. If the child can tolerate sleeping in prone and it is safe, this is also recommended.

Adductor lengthening

Tight adductor muscles cause the legs to cross over as well as the pelvis to drop in standing and walking.

After surgery, the most important position is with legs apart. The legs should be kept apart as much as possible. As the adductor muscles can be very tight, it may take considerable time to stretch the legs apart each time they are allowed to come together.

Hamstring lengthening

Tight hamstring muscles may be responsible for knees that don’t want to straighten. After surgery the child must keep the knees straight. Use of a knee brace or a cast is required. As the legs are kept straight, a wheelchair with raised leg rests will be needed and can be hired.

The child should not sit with knees bent if possible. Exceptions can be made for sitting on a toilet or when travelling short distances in a car. Specific time should be set aside for long sitting with legs apart as guided by your therapist.

Semitendinosis transfer

Tight hamstring muscles may be responsible for knees that don’t want to straighten. This procedure involves taking one hamstring muscle (there are four) and transferring one end from below the knee to the side or above the knee. This reduces the amount of knee-bending force, whilst maintaining the ability to extend at the hips.

After surgery, a knee brace or a cast will be required if the legs do not stay straight on their own. The surgeon may restrict hip flexion to 45°. This will mean that the child cannot sit upright and needs a chair that can recline. As the legs are kept straight, a wheelchair with raised leg rests is also needed. A reclining chair with leg raises can be hired.

The child should not sit with knees bent if possible. Exceptions can be made for sitting on a toilet or when travelling short distances in a car. Specific time should be set aside for long sitting with legs apart for 1-2 hours each day.

Rectus femoris transfer / Rectus femoris release

The rectus femoris muscle is a long strap-like muscle which runs from just above the hip to the knee cap. Its function is to straighten the knee and bend the hip.

Some children have spasticity in this muscle which makes it difficult to bend the knees, such as when sitting down. As the knee should bend when swinging the leg forward to make sure we don’t trip, it is difficult to walk with spasticity in this muscle.

A rectus transfer involves separating the muscle and reattaching it to a muscle or tendon that is attached beside or behind the knee. This gives this muscle the opposite effect when contracted. Instead of straightening the knee it will bend the knee. After surgery, a specific protocol is used to ensure the knee does not become stiff.

A rectus release involves making an incision in the muscle above the knee to allow it to lengthen. This will improve the ability to bend the knee while walking.

The knee is kept straight all day and night except when doing exercises. The exercises involve removing the leg brace and bending the knee gently. The knee is bent and straightened as indicated by your orthopaedic surgeon. Taking muscle relaxants and pain medication prior to the exercises can help. The bending also allows the knee to become familiar with the altered function of the rectus femoris muscle which now bends the knee instead of straightening it.

Some time in the first two weeks following surgery, pain improves however the knee can be stiff. The child should sit for three hours either in the morning or afternoon with the feet unsupported. The weight of the feet will help with stretching. The knee should be kept straight for the rest of the day.

The simple rule is “keep the knee straight unless you are bending it”. The knee will become stiff without the exercises which is very important. The goals are set at 30° bending for first week, 60° bending for second week and 90° for the third week.

Calf lengthening

Tight calf muscles may be the cause of a child who walks on tip-toes. This may reduce balance and make walking more difficult. There are many different ways of lengthening the calf muscle.

The type of procedure used will often depend on the tightness of the muscle. After surgery, care must be taken not to over-stretch the muscle after surgery. This is prevented by using a cast and an AFO is used to keep the ankle in an ideal position. Once the calf has healed at the correct length, the AFO may be hinged to allow ankle movement.

Plantar Fascia lengthening

A tight band of tissue that runs along the sole of the foot can contribute to a high arch and is common in children who walks on their toes. This may contribute to areas of pressure building up and can make walking more difficult.

The type of procedure is often completed in conjunction with a calf lengthening. After surgery, a cast and AFO are used to keep the ankle at an ideal position.

Tibialis posterior lengthening

A tight tibialis posterior muscle may cause the foot to point and turn in. It may also be responsible for a very high arch.

After surgery, a cast is used to maintain the correct foot position. This is generally replaced by an AFO after removal of the casts.

Split Anterior Tibialis Tendon Transfer (SPLATT)

The anterior tibialis muscle lifts the foot up, however it also turns the sole of the foot in because it attaches to the inner side of the top of the foot. A tight anterior tibialis muscle may be responsible for a foot that is turned in.

The surgery involves taking part of the tendon from the inside of the ankle and reattaching it to the outside. After surgery a cast is used to maintain the correct foot position. This is generally replaced by an AFO after a few weeks.

Split Posterior Tibialis Tendon Transfer (SPOTT)

The posterior tibialis muscle turns the foot in and assists in maintaining the midfoot arch. A tight posterior tibialis muscle may be responsible for a foot that is turned in.

The surgery involves taking part of the tendon from the inside of the ankle and reattaching it to the outside. After surgery a cast is used to maintain the correct foot position. This is generally replaced by an AFO after a few weeks.

Contact us

Queensland Paediatric Rehabilitation Service
Queensland Children’s Hospital
Level 6, 501 Stanley Street, South Brisbane 4101
t: 07 3068 2950
t: 07 3068 1111 (general enquiries)
f: 07 3068 3909
e: qprs@health.qld.gov.au

In an emergency, always call 000.

If it’s not an emergency but you have any concerns, contact 13 Health (13 43 2584). Qualified staff will give you advice on who to talk to and how quickly you should do it. You can phone 24 hours a day, seven days a week.

Resource No: FS199. Developed by the Queensland Paediatric Rehabilitation Service, Children’s Health Queensland. Updated: August 2015. All information contained in this sheet has been supplied by qualified professionals as a guideline for care only. Seek medical advice, as appropriate, for concerns regarding your child’s health.

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