CP - SEMLS

Question 1

What are the different types of orthopaedic surgery in CP?

Answer 1

• Contracture release (e.g. hip flexion, hip adductors, hamstrings, calf)
• Tendon transfers (e.g. split tib post, rectus femoris)
• Bony (e.g. proximal/distal femoral derotation, tibial supramalleolar derotation osteotomies)
• Subtalar fusion or calcaneal lengthening
• Epiphyseodesis

Question 2

When is hip adductor release performed?

Answer 2

Early in response to hip surveillance findings to prevent hip subluxation

Question 3

When is calf lengthening performed?

Answer 3

• Due to fixed contracture that no longer responds to BTx , serial casting & orthotics
• Recommended surgery is a Strayer procedure rather than tendo-Achilles lengthening (TAL)

Question 4

What is a precaution for calf lengthening?

Answer 4

• Care must be taken not to over lengthen as this results in crouch gait
• Need to leave soleus intact where possible

Question 5

What is SEMLS?

Answer 5

• Single event multilevel surgery
• Directed at type III & IV hemiplegics &
  diplegics who have predominantly spastic movements (not
  athetoid)

Question 6

What are the aims of SEMLS?

Answer 6

• Correct deformity
• Improve “lever arm dysfunction”
• Improve gait pattern
• Reduce the energy cost of walking

Question 7

What are the characteristics of the ideal candidate for SEMLS?

Answer 7

• Independent walker
• Compliant
• Well motivated
• Supported
• Prior to pre-pubertal growth spurt

Question 8

What is the duration of SEMLS?

Answer 8

• Up to 16 combined soft tissue & bony surgeries in a single operation
• 4-6hrs duration with 2 surgeons

Question 9

What typically happens post-op SEMLS?

Answer 9

• Hospitalised for 1 week
• Rehab for 6-12 months post operative
• Family need to be aware of post-op requirements & therapy services organised

Question 10

What may be involved pre-op SEMLS?

Answer 10

• Preoperative planning 3DGA + physical Ax

- May also assess oxygen consumption

Question 11

What are the surgery principles of SEMLS?

Answer 11

• To give a solid base (foot/ankle) that is directed straight ahead (tibial & femoral torsion) with effective joint ROM
• Bony surgery must have sufficient fixation to allow for early mobilisation

Question 12

What equipment is used for immobilisation post SEMLS?

Answer 12

• Hip spica
• Broomstick casts
• Zimmer splints
• SL Plasters

Question 13

What are the rehab principles for SEMLS?

Answer 13

• Adequate pain management acutely
• Monitoring of plasters & positioning
• Early & regular stretches/joint ROM
• Hydrotherapy important ASAP
• Appropriate & timely orthotic use
• Intensive and prolonged physio (significantly
  weakened by surgery)

Question 14

What information should be communicated to families when setting goals for surgery in CP?

Answer 14

• Goals of surgery and its limitations
• Child still has cerebral palsy
• Soft tissue surgery 6 month recovery time
• Bony surgery 12 month recovery time
• Recovery time refers to child returning to pre GMFCS level and mobility (FMS)

Question 15

What is involved in rehabilitation after surgery?

Answer 15

• Period of NWB depending on surgery and surgeon, designed to be as short as possible
• Positioning & plaster care
• Skin care and pressure areas
• Chest check
• Medical review & removal of casts
• Intensive inpatient rehab for approx 2 weeks.
• Intensive physio for the following 3 months for soft tissue surgery & 9 months for bony surgery
• Surgical review 12 months post op
• Removal of internal fixators and further minor
  surgery planned

Question 16

How can equipment needs change after surgery?

Answer 16

High equipment needs for short time post surgery which may not have been previously required (need OT referral)

Question 17

What are the physio rehab aims post surgery?

Answer 17

• Maintain muscle length (prone lying, long sitting, avoid side lying, long term monitor hip abductor length)
• Strengthening program (quads, gluteals, hamstrings)
• Increase knee ROM, early knee flexion to prevent adhesions (should be 90deg prior to discharge)
• Standing (ensure good alignment especially hip
  & knee extension)
• Transfer practice
• Gait retraining

Question 18

What are the orthotics that may be used post surgery?

Answer 18

• GRAFO
• Static AFO
• Hinged AFO
• Assess need for ongoing orthotics – surgeon or when reaches skeletal maturity

Question 19

What are the gait aids that may be used post surgery?

Answer 19

• Posterior walker
• Quad sticks
• Canadian crutches

Question 20

What are the goals 6-12 months after SEMLS?

Answer 20

• Maintain compliance & motivation by incorporating other activities into the program e.g. bike riding
• Prevention of burn out by integration into recreational and social exercise activities, or return to sports

Question 21

What are the potential complications of orthopaedic surgery?

Answer 21

• Under/over correction of long bone torsion
• Over lengthening of muscles
• Nerve traction injuries has the biggest effect on rehab due to pain, hypersensitivity and inability to weight bear
• Pressure sores from plasters and zimmer splints

Question 22

What are some of the other issues associated with orthopaedic surgery?

Answer 22

• Equipment provision from local service or tertiary hospital
• Little or no pre-op contact with patient, family or therapists
• Limited understanding of family of what is required post-op
• Locating local therapy services