Chapter 25 Lower Extremity Surgical Intervention in Patients with Cerebral Palsy

Bone and Musculotendinous Procedures

Deborah Corradi-Scalise, PT, DPT, MA, Cathi Wagner, PT, MBA, Amanda R. Sparrow, PT

Cerebral palsy (CP) is defined as a condition characterized by a chronic, nonprogressive disorder of movement or posture of early onset. It presents as abnormal control of motor function/coordination as a result of damage to one or more specific areas of the brain. The damage to the brain can occur during the prenatal, perinatal, postnatal, as well as the infancy period. The primary lesion is static; however, the manifestations can change, especially in the musculoskeletal system, because of muscle imbalances, growth, development, and the effects of gravity.

Rehabilitation Overview

Preoperative Considerations

• Orthopedic management of a child with CP is best accomplished via a team approach.

• The medical and rehabilitation team must consider the “total” child when evaluating a patient with CP for surgical intervention.

• An understanding of atypical development and movement compensations is imperative to determine how surgery will likely impact the child’s future function.

1 Muscular tightness and joint limitations at any one joint impact the alignment and function of adjacent muscles and joints.

2 Surgically treating one problem, without consideration of the rest of the body in CP, may have a poor outcome.

3 Additionally, one must also remember that lengthening a muscle also weakens it. This is very important to remember when considering any surgical procedure in the ambulatory patient.

4 The current trend in orthopedic surgery is to develop a strategy and prepare an operative plan that addresses all of the patient’s impairments at one time.

• Additionally, a differentiation must be made between primary impairments and secondary compensations to adequately address CP.

• A comprehensive physical therapy examination for each presurgical candidate should be performed and the findings discussed with the team.

• Another tool that may be used in the preoperative evaluation process is quantitative gait analysis.

1 Gait analysis, using a three-dimensional (3-D) motion analysis laboratory, provides the clinician with important objective data.

2 Kinematic, kinetic, and electromyographic (EMG) data collected in this fashion help identify, simultaneously, the presence of multiple abnormalities (bone and soft tissue) at multiple levels, in three anatomical planes.

3 Gait analysis provides the team with data to assist in the differentiation of primary gait deviations and secondary coping strategies.

Postoperative Considerations

• Immediate postoperative concerns for any surgical procedure in the patient with CP include pain and spasm management and decreasing the anxiety level of both the child and caregiver/family.

• It is important to overcome the early weakness, stiffness, and discomfort postoperatively.

1 Rapid mobilization following surgery is essential in overcoming early postoperative stiffness and weakness; however, traumatized muscles should be given enough time to recover, and the child should be as comfortable as possible when beginning therapy.

2 Analgesic medication and muscle relaxants are used immediately postoperatively.

3 A compassionate and supportive staff is also essential to help the patient and family during the postoperative rehabilitation phase.

• Postoperative rehabilitation focuses on:

1 The restoration of range of motion (ROM)

2 Regaining preoperative muscle strength

3 Optimizing mobility/gait and functional ability.

• All goals will be directly related to and dependent upon the overall functional ability of the patient.

1 During the initial rehabilitative period, it may be beneficial to use splints for comfort and prevent joint positioning that could contribute to recurrent contractures.

2 If only soft tissue procedures have been performed, ambulation typically begins on postoperative day one (POD 1). If bone procedures are performed, radiographic evidence of bone healing and physician clearance are necessary before initiating weight-bearing activities.

3 When multiple surgical procedures are performed on the lower extremity, it may take a long time for the patient to regain preoperative level of strength and function.

• A home exercise program (HEP) will greatly assist the patient in the recovery and rehabilitative process.

1 The patient’s HEP is continually updated based on evaluative findings.

2 Compliance to the HEP is very important and should be reinforced with the patient and family.

3 In the rehabilitation process of a patient with a primary neurological impairment, it is important to incorporate principles of motor learning into the treatment program.

4 Direct hands-on therapeutic input, in addition to providing the patient with feedback through all of the sensory systems, is important.

5 Repetition is necessary for learning a movement skill, and a focus on functional tasks will provide meaning to the activity for the patient.

• It is very important that the medical team identify and address the patient/family goals when making decisions regarding surgical interventions.

1 Typically, there is an increase in frequency of physical therapy intervention postoperatively for a period of time to address the immediate weakness and functional limitations/disability associated with surgical lengthening, bone procedures, and immobilization.

2 Once the acute and subacute phase of rehabilitation is complete, the patient typically returns to his or her preexisting, preoperative therapeutic program.

The following pages provide postoperative guidelines following bone and joint tissue surgical procedures commonly performed at HSS for the management of CP. For the sake of clarity, only one anatomical deformity/surgery is presented at a time. The reader must realize that, characteristically, many of the deformities coexist in patients with CP and therefore multiple surgical procedures are typically performed simultaneously. The total rehabilitation course must reflect this and be coordinated/modified according to the surgical procedures performed on each individual patient. As always, the physical therapist should maintain open communication with the treating surgeon on how to progress each individual patient.

Varus Rotational Osteotomy

• Children with CP commonly present with coxa valga and excessive femoral anteversion, as reported on radiograph.

1 Both of these findings can contribute to hip subluxation and dislocation.

2 Functionally, increased femoral anteversion presents as an in-toeing gait pattern.

3 Excessive hip internal rotation during gait carries with it an associated cosmetic and functional disability.

4 Increased femoral anteversion can result in hip flexion and adduction contractures with shortening of the psoas muscles. This can lead to hip instability and subsequent hip subluxation or dislocation.

• The varus rotational osteotomy (VRO) is a surgical intervention performed to correct femoral anteversion, coxa valga, and hip subluxation.

1 The goal of this procedure in individuals with CP is to improve cosmetic and functional gait parameters as well as stabilize the hip joint.

2 In individuals with CP, VRO outcomes have reportedly included an increase in hip external rotation and extension, a decrease in anterior pelvic tilt, and an increase in knee extension strength.

3 Surgical indications are based on clinical examination, gait analysis, and radiographic findings.

• Indications for a VRO are:

1 In-toeing gait with excessive femoral anteversion greater than 40 to 45 degrees.

2 Clinically, passive internal rotation greater than 45 degrees with less than 30 degrees of external rotation on physical exam.

3 Hip subluxation.

Surgical Overview

• The VRO procedure is performed prone, as described by Dr. Leon Root.

• An osteotomy is performed at the upper level of the lesser trochanter in the intertrochanteric aspect of the femur.

• The osteotomy is positioned to prevent extension or flexion.

• The blade portion is inserted through the greater trochanter into the neck of the femur.

• The distal femur is then clamped to a plate.

• The distal femur is rotated externally, and the head and neck are placed in decreased valgus.

• The femoral head is centered into the acetabulum, and the femoral anteversion is corrected.

• The proximal screw is inserted, and the ROM is evaluated.

• The goal is to have an approximate 2:1 ratio (60 to 30 degrees) of hip external to internal rotation.

1 If the desired rotation is achieved, then the remaining screws are inserted.

2 If not, the proximal screw is removed, and the degree of rotation is modified.

Rehabilitation Overview

• The rehabilitation following a VRO is designed to progressively increase range of joint motion, muscle strength, and the patient’s ability to resume lower extremity weight-bearing activities.

• Communication between the physical therapist and the surgeon is imperative. The surgeon will assess bone healing via radiograph and advise the therapist when the healing is sufficient to begin weight-bearing activities in therapy.

Postoperative Rehabilitation of VRO: Phase I (Days 2 to 4) with Spica Cast

GOALS

• Control of postoperative pain/spasm

• Frequent changes of position: side-lying/prone and sitting in a reclining wheelchair (typically days 2 to 3)

• Ensure that the cast fits appropriately and does not impede circulation or cause irritation

• Maintain patient non-weight-bearing status

• Caregiver independent in patient transfers

PRECAUTIONS

• Avoid prolonged periods of lying in supine

• Monitor skin for irritation/breakdown from cast and positioning

• Monitor distal extremities for signs of edema

TREATMENT STRATEGIES

• Caregiver instructed to monitor the cast for fit and skin irritation

• Caregiver education in importance of position changes

1 Prone

2 Side-lying

3 Supine

4 Sitting

• Caregiver instructed in proper body mechanics for transfers

CRITERIA FOR ADVANCEMENT

• Dependent upon bone healing seen on radiograph; determined by the surgeon

Postoperative Rehabilitation of VRO: Phase I (Days 2 to 4) with Jordan Splints; No Casting

GOALS

• Control of postoperative pain/spasm

• Educate patient/caregivers regarding hip precautions

• Frequent changes of position (maintaining hip precautions) to prevent decubiti and decrease fear of movement

• Develop ability to sit in a reclining wheelchair

• Develop/maintain passive range of motion (PROM) of lower extremities maintaining hip precautions

• Educate caregivers on transfers and importance of maintaining non-weight-bearing status

PRECAUTIONS

• Avoid prolonged periods of lying in supine

• Maintain hip precautions of no adduction or internal rotation past neutral; no flexion past 90 degrees

• Hip external rotation; extension and abduction as tolerated

• The patient is typically non-weight-bearing for at least 3 weeks, but this is dependent on bone healing and clearance by the surgeon

Therapeutic Strategies

• Frequent change of position

1 From supine to side-lying with pillows to maintain hip abduction and neutral rotation

2 Reclining wheelchair with knees flexed if tolerated (typically PODs 2 to 3)

• Gentle PROM of the hips, within precautions of hip flexion to 90 degrees, hip internal rotation to neutral, hip adduction to neutral; hip external rotation, extension, and abduction as tolerated

• Gentle PROM of the knees and ankles may begin POD 2

• Active ankle pumps

• Training patient/caregiver regarding hip precautions and the importance of position change

CRITERIA FOR ADVANCEMENT

• Dependent upon bone healing seen on radiograph; determined by the surgeon

Postoperative Rehabilitation of VRO: Phase II (Days 5 to 21) with Spica Cast

GOALS

• Controlling postoperative pain/spasm

• Ensure that cast fits appropriately and does not impede circulation or cause irritation

• Frequent changes of position to side-lying, prone, and up to reclining wheelchair

• Patient maintains non-weight-bearing until clearance from surgeon

PRECAUTIONS

• Avoid prolonged periods of lying in supine

• If patient is allowed to stand in the spica cast at home, supervision and support must be given at all times

TREATMENT STRATEGIES

• Caregiver/patient education and importance of position changes

• Caregiver instructed in transfers

• The surgeon may allow the patient to stand in the spica cast at home

CRITERIA FOR ADVANCEMENT

• Dependent upon the bone healing seen on radiograph; determined by the surgeon

Postoperative Rehabilitation of VRO: Phase II (Days 5 to 21) with Jordan Splints

GOALS

• Control of pain/spasm

• Decrease fear of movement

• Sitting in a wheelchair for longer periods of time

• Active and active-assisted motion of the lower extremities

PRECAUTIONS

• Avoid prolonged periods of lying in supine

• Maintain hip precautions of no adduction or internal rotation past neutral; no hip flexion past 90 degrees

• Hip external rotation; extension and abduction as tolerated

• The patient is typically non-weight-bearing for at least 3 weeks, but this is dependent upon the bone healing and clearance by the surgeon

TREATMENT STRATEGIES

• Control of postoperative pain and swelling

• Frequent change of position

1 To side-lying with pillows between legs to maintain hip abduction and neutral rotation

2 Reclining wheelchair, moving the trunk toward an upright position with knees flexed

• Passive, active-assisted, or active range of motion (AROM) of the hips, knees, and ankles as tolerated, to include heel slides, hip abduction with neutral hip rotation, quad sets, ankle pumps

• Review with caregiver/patient the importance of position changes and sitting in wheelchair with the knees flexed

CRITERIA FOR ADVANCEMENT

• Dependent upon the bone healing seen on radiograph; determined by the surgeon

Postoperative Rehabilitation of VRO: Phase III (Weeks 3 to 6) with Spica Cast-Cast Removal

Note: If there is adequate bone healing on radiograph at 3 weeks, the orthopedist may choose to remove the cast. Following cast removal, physical therapy will begin when prescribed by the physician.

GOALS

• Control pain and spasm

• Decrease fear of movement

• Upright sitting in wheelchair

• Increase ROM of hips/knees/ankles, maintaining hip precautions

• Initiate weight-bearing

• Begin lower extremity active movement and strengthening

PRECAUTIONS

• Continue to avoid periods of prolonged static positioning

• Maintain hip precautions

• Weight-bearing to patient’s tolerance, with appropriate therapist support and assistive device

TREATMENT STRATEGIES

• Frequent changes of position: prone/supine/sitting/side-lying with pillows between legs to maintain neutral hip abduction and rotation

• Passive, progressing to AAROM and AROM of hips, knees, and ankles as tolerated, maintaining hip precautions

• Gluteal sets

• Quadriceps sets

• AROM/AAROM of the hips, knees, and ankles

1 Supine hip abduction, adduction to neutral

2 Heel slides for hip and knee flexion

3 Ankle dorsiflexion and plantar flexion

• Gentle stretching/elongation of the hip flexors, hamstrings, quadriceps, and gastrocsoleus as tolerated

• Initiation of weight-bearing can be achieved using the therapy ball to move from prone to standing with support. Increasing the amount of time and decreasing the amount of support as the patient progresses

• Weight-bearing with appropriate assistive device to begin as prescribed by surgeon

• Weight-shifting facilitated in sitting/standing to assist body to readjust to new lower extremity orientation

• HEP—warm water bath may aid in relaxation for performance of gentle ROM exercises

CRITERIA FOR ADVANCEMENT

• Dependent upon strength and ROM in the lower extremities as well as patient tolerance

Postoperative Rehabilitation of VRO: Phase III (Weeks 3 to 6) with Jordan Splints

Note: If there is adequate healing on radiograph at 3 weeks, the orthopedist may allow the patient to begin weight-bearing.

GOALS

• Control pain and spasm

• Decrease fear of movement

• Initiate weight-bearing

• Improve ROM of the lower extremities

PRECAUTIONS

• Maintain hip precautions of no adduction or internal rotation past neutral; no hip flexion past 90 degrees

• Weight-bearing to patient’s tolerance

TREATMENT STRATEGIES

• Frequent position changes as previously described

• Passive, progressing to AAROM to AROM of the hips, knees, and ankles as tolerated; heel slides for hip and knee flexion, supine hip abduction with neutral rotation, adduction to midline

• Begin lower extremity active-assistive/active movements against gravity if able

• Ankle pumps

• Gluteal sets

• Quadriceps sets

• Ankle dorsiflexion and plantar flexion

• Gentle stretching/elongation of the hip flexors, hamstrings, quadriceps, and gastrocsoleus as tolerated

• Facilitate weight-shifting in sitting forward over feet to assist body to readjust to new lower extremity orientation and begin to accept weight through lower extremities

• Progressive weight-bearing with appropriate assistive device as prescribed by orthopedist

CRITERIA FOR ADVANCEMENT

• Dependent upon strength and ROM in the lower extremities

Postoperative Rehabilitation of VRO: Phase IV (Week 6 to Month 9 or Full Recovery)

GOALS

• Develop/increase lower extremity ROM

• Strengthen lower extremities

• Improve quality of ambulation and progress ability and endurance ambulation with or without assistive device

• Return to or surpass the patient’s functional level before surgery

PRECAUTIONS

• Avoid pain with therapeutic exercise and functional activities

• Avoid jumping/ballistic or high impact activities

TREATMENT STRATEGIES

• Core muscle strengthening exercises

• Sit to stand with facilitation; grade assistance as needed

• Qualitative gait training; work toward normalized gait pattern

• Endurance gait training

• Total gym activities (progressive weight-bearing and strengthening)

• Stationary bicycle

• Treadmill walking-forward, sideways, and retroambulation

• Stair negotiation

• Hip abduction in standing

• Single leg stance activities

• Side stepping with neutral rotation

• Return to typical physical therapy routine/program

Hip Flexors Release

• Excessive hip flexion is a common deformity in CP. Most hip flexor deformities are caused by a tight iliopsoas unit.

• A physical exam may reveal hip flexor spasticity or a hip flexion contracture.

1 Impairments associated with excessive hip flexion are restricted stride length during gait, excessive anterior pelvic tilt, excessive lordosis, hip dysplasia, subluxation, and dislocation.

2 A hip flexion contracture of more than 20 degrees is clinically significant because it may contribute to hip instability.

• The goal of a hip flexor release is to decrease static contractures, rebalance the muscles around the hip joint to aid in hip stability, allow for functional hip extension during gait in ambulatory children, and preserve the ability of the psoas to function appropriately in a concentric fashion.

• Ambulatory children should have tenotomy of the psoas tendon alone (not the iliacus fibers) performed over the brim of the pelvis.

• Indications for a hip flexor release are

1 Hip flexion contracture greater than 15 to 20 degrees

2 Radiographic measurement of the sacrofemoral angle is less than normal (40 to 60 degrees).

3 Hip flexor contracture associated with hip instability (subluxation)

Surgical Overview

• The surgical procedure for release of the psoas muscles is performed with the patient supine.

• An oblique incision is made 2 cm below the anterior superior iliac spine to visualize the sartorius, tensor fascia lata (TFL), and the lateral femoral cutaneous nerve.

• The TFL is reflected to visualize the anterior inferior iliac spine and rectus femoris.

• The iliacus is retracted to reveal the tendon of the psoas, where it lies under the iliacus muscle.

• The psoas is then transected.

• In selected cases, when applicable, the TFL can be lengthened by incising the aponeurosis through the same incision.

Rehabilitation Overview

• Rehabilitation for a hip flexor release focuses on early ROM, positioning the patient to maintain the new muscle length, mobility out of bed to include ambulation (as functional level permits), and the return of the patient to his or her preexisting therapeutic program as soon as possible.

• No casting or splinting is used postoperatively post-hip flexor release.

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