Magazine article The Exceptional Parent

Orthopedic Surgery

Magazine article The Exceptional Parent

Orthopedic Surgery

Article excerpt

Cerebral palsy affects the way muscles work and can distort growing bones by creating abnormal forces on them. Because standing and walking are often delayed in children with cerebral palsy, the hip joints do not receive the normal weight-bearing stimulation to form properly. Also, spastic muscles can deform growing bones.

Although doctors cannot cure cerebral palsy, we can help to modify its effects by decreasing muscle tone, surgically improving muscle balance, and by preventing and correcting the mal-alignment of limbs to help with standing, walking, or even sitting.

Certain problems are common among children with cerebral palsy. When children with spasticity begin to stand, they often do so on their toes with their knees bent. As they attempt to walk, their legs may cross or scissor so that their progress is impeded. We attempt to align the limbs to facilitate standing or walking first through physical therapy and the use of orthotics. Orthopedic surgery is often necessary to improve these functions, by releasing or transferring contracted muscles. Operations on several muscles are usually performed at the same time.

Muscle lengthening

The term, "muscle lengthening" may be confusing. The tendon part of the muscle, or in some instances a portion of the muscle itself, is released so that the length of the muscle is elongated, allowing greater movement of the joint. For example, if the child "toe walks," then lengthening the heelcord allows the heel to strike the ground in a more normal pattern. If the hamstring muscles are tight, causing a bent-knee walk, these can be lengthened individually to achieve a desired range of movement. If the hip adductors or groin muscles are tight, these can be lengthened in the inner aspect of the groin.

The actual surgical technique may vary according to each situation or doctor's preference. After muscle lengthenings are done, postoperative care and rehabilitation are very important. The lengthened muscle is always weaker following surgery, so it is essential to get back to moving it again in rehabilitation therapy, to restore joint mobility and regain muscle strength. I personally advocate minimal casting or immobilization following adductor or hamstring surgery, and limited cast immobilization for heelcord lengthening. I encourage casting and walking two days after surgery, progressing as pain and discomfort subsides. The sooner the child regains mobility, the sooner she returns to her normal level of function.

Tendon transfers

Tendon transfers make the muscle work in a different way than nature intended. For instance, a child walking on his toes and the outer border of his foot, then the heel cord and the muscle on the inner aspect of the ankle and foot (the posterior tibial muscle) are fight. In this instance, the heelcord would be lengthened and the tendon of the posterior tibial muscle would be split longitudinally, leaving a portion attached to its normal site, and taking the other detached portion around the back of the ankle and re-attaching it to a tendon on the outer aspect of the foot When the muscle contracts, it pulls on the inner and outer aspect of the foot simultaneously, so that the foot is flat on the floor with weight bearing.

Occasionally, the entire tendon is moved so the muscle elicits an opposite reaction to its normal one. An example of this is the middle muscle in front of the thigh (the rectus femoris). This muscle has two functions: 1) to lift the thigh and flex the hip at the same time, and 2) to straighten or extend the knee. …

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