35.1 Introduction

Single-event multilevel surgery of the lower extremity (SEMLS) is an excellent surgical option for a diplegic cerebral palsy (CP) patient. ^{1 – 5} Other associated pathologies that may benefit from these soft tissue releases may be traumatic, idiopathic, or congenital, such as a foot drop, tip toeing, or hip dysplasia in a healthy child, respectively. ^{3 , 4} It is recommended to delay SEMLS until age 7 if possible, to maximize its benefits. ² Theses procedure will provide the patient with an increased range of motion, which may aid in mobilization or aid care-takers in daily activities such as dressing and positioning.

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  A patient with isolated gastrocnemius tightness confirmed by a positive Silfverskiold test will benefit from a gastrocnemius recession. ^{1 – 5} Decreased ankle dorsiflexion may be associated with a club foot or a syndrome such as CP. The form of gastrocnemius recession performed is a Strayer procedure, which is a distal recession of the gastrocnemius and only lengthens the gastrocnemius portion of the gastrosoleus complex, but can be combined with soleus lengthening. ^{2 , 3} The release may also be performed with a scope, which will not be described here.

  
  
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  Hamstring tightness and progressive knee flexion contractures interfere with gait and activities of daily living. ⁵ A straight leg raise test and measurement of popliteal angel is used to assess hamstring contracture. In a child with normal neurological function of the lower extremity, excessive hamstring release may cause nerve damage through traction. Hamstring lengthening and rectus femoris transfer versus lengthening are indicated in the CP patient with a crouching gait. ^{1 – 3}

  
  
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  Increased hip abduction aids in maintaining hip reduction in a dysplastic hip and can also aid with the mobilization and daily care of a syndromic child. ⁴ Percutaneous adductor release can be performed, but risks damage to neurovascular structures. Open release of hip adductor longus and gracilis will be described. Tenotomy of hip flexors iliopsoas may also be added in CP patient with hip subluxation.

35.2 Preop

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  For each procedure, a similar preoperative plan and set up may be used (▶Fig. 35.1). General anesthesia is preferred to achieve the maximum relaxation of musculature.

  
  
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  A flat table with patient feet pulled to end is used; a radiolucent table is not necessary.

  
  
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  Patient position. Supine with arms padded on/off arm boards depending on patient size

  
  
  
  

  Gastrocnemius lengthening may be performed in prone position but is usually performed at the same time as other soft tissue releases, making supine position easier.

  
  
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  Patient exam. While patient is under anesthesia, passive hip abduction, knee flexion, and ankle dorsiflexion may be evaluated.

  
  
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  Equipment. Thigh tourniquet, ioban, right angle clamp, retractors including rag-nail, sofield, Army-Navy, electrocautery, scalpel