Orthopedic Surgery

Orthopedic surgery is most often recommended in children with muscles that are dysphasic, firing out of phase, or those muscles that show excessive activity while working in phase, thereby overpowering their antagonist and thereby inhibiting smooth joint motion (181).

When improved function is the goal of surgery, multiple muscles and joints may be targeted because they are all interrelated in specific movement patterns; therefore, a single multilevel surgical procedure is more common than multiple staged surgeries (183-185). A common multilevel soft tissue surgical approach includes three procedures: the hamstring lengthening, rectus femoris transfer, and gastrocsoleus lengthening (186). Assessment of mobility after multilevel surgery for CP with use of a functional walking scale was per­formed in 85 nonambulatory children who were able to attain independent sitting balance by the age of 5 to 6 but who did not have access to previous spas­ticity management (187). Significant improvements in joint contractures were noted in addition to the fact that all patients gained walking capabilities, includ­ing one-third of the patients ambulating community distances (187).

Orthopedic surgery is ideally delayed until the age of 4 to 7 years, due to the high risk of recurrence of tightness and contracture formation in younger chil­dren (182,183,188).

Postoperative care should include aggressive pain management to minimize pain-related muscle spasms, which may further increase discomfort. Rapid mobi­lization with minimal casting is also recommended, usually with only a two- to three-day period of recum­bency following surgery. The need for physical ther­apy should be assessed and started as soon as possible if necessary to minimize postoperative weakness and disuse atrophy, as well as improve muscular reedu­cation and training in those muscles or tendons that were manipulated.

Surgical spinal fusion is not uncommon in CP. Indications for surgical management may vary between centers, but, in general, curvatures greater than 40 degrees in skeletally immature persons and greater than 50 degrees in skeletally mature persons are recommended for evaluation and consideration of possible fusion surgery (189). Before pursing spinal fusion, the child should receive careful preoperative evaluation and preparation, including close moni­toring of nutrition and respiratory status in order to reduce postoperative complications. Goals of surgical intervention include prevention of curve progression with subsequent pulmonary and skin complications, as well as improved sitting balance, positioning, and comfort.