CP - SEMLS Flashcards
What are the different types of orthopaedic surgery in CP?
- 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
When is hip adductor release performed?
Early in response to hip surveillance findings to prevent hip subluxation
When is calf lengthening performed?
- 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)
What is a precaution for calf lengthening?
- Care must be taken not to over lengthen as this results in crouch gait
- Need to leave soleus intact where possible
What is SEMLS?
- Single event multilevel surgery
- Directed at type III & IV hemiplegics &
diplegics who have predominantly spastic movements (not
athetoid)
What are the aims of SEMLS?
- Correct deformity
- Improve “lever arm dysfunction”
- Improve gait pattern
- Reduce the energy cost of walking
What are the characteristics of the ideal candidate for SEMLS?
- Independent walker
- Compliant
- Well motivated
- Supported
- Prior to pre-pubertal growth spurt
What is the duration of SEMLS?
- Up to 16 combined soft tissue & bony surgeries in a single operation
- 4-6hrs duration with 2 surgeons
What typically happens post-op SEMLS?
- Hospitalised for 1 week
- Rehab for 6-12 months post operative
- Family need to be aware of post-op requirements & therapy services organised
What may be involved pre-op SEMLS?
- Preoperative planning 3DGA + physical Ax
- May also assess oxygen consumption
What are the surgery principles of SEMLS?
- 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
What equipment is used for immobilisation post SEMLS?
- Hip spica
- Broomstick casts
- Zimmer splints
- SL Plasters
What are the rehab principles for SEMLS?
- 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)
What information should be communicated to families when setting goals for surgery in CP?
- 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)
What is involved in rehabilitation after surgery?
- 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
How can equipment needs change after surgery?
High equipment needs for short time post surgery which may not have been previously required (need OT referral)
What are the physio rehab aims post surgery?
- 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
What are the orthotics that may be used post surgery?
- GRAFO
- Static AFO
- Hinged AFO
- Assess need for ongoing orthotics – surgeon or when reaches skeletal maturity
What are the gait aids that may be used post surgery?
- Posterior walker
- Quad sticks
- Canadian crutches
What are the goals 6-12 months after SEMLS?
- 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
What are the potential complications of orthopaedic surgery?
- 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
What are some of the other issues associated with orthopaedic surgery?
- 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
