Orthopedic Surgery

Orthopedic surgery can play an important role in the treatment of spasticity / tightness / contracture / deformity. The development of aseptic technique and more reliable anesthesia allowed expansion of surgical options to more complex procedures, including neurectomies, fasciotomies, osteotomies, and arthrodeses.

It is stressed the importance of careful preoperative assessments, selection of appropriate operative procedures, and extensive and prolonged postoperative care. 

Goals of surgical treatment
The goals of orthopedic surgery in both cerebral palsy and acquired spasticity are to increase mobility, decrease the use of external aids, correct or prevent deformity and ultimately maximize function.

Chronic spasticity may lead to fixed soft tissue contracture or bony deformities. When these do not respond to conservative measures such as manual stretch, serial casting, and use of Botox / phenol and are of functional significance to the patient, surgical treatment can be the best option.

Surgery also has a role in the treatment of spasticity in the absence of fixed deformity. A neurectomy can decrease spasticity through interruption of the reflex arc. Procedures that separate the spastic muscle from its insertion or lengthen its tendon can eliminate its action on the limb or reduce its mechanical advantage.

Furthermore, such procedures may, by reducing the stretch on the muscle, decrease the spindle afferent impulses and the resulting spasticity. The specific techniques include tendon lengthening, tendon transfer, neurectomy, osteotomy, resection arthroplasty, and arthrodeses. Joint realignment (osteotomy) and resection or fusion (arthrodeses) is required when joint or bony deformity has developed.

Tendon lengthening is used to rebalance agonist-antagonist muscle groups, or correct musculotendinous unit contractures. Tendon transfers have limited indications because of the difficulty in assessing the strength and volitional control of spastic muscles. The joint that is be mobilized by the tendon transfer should have a full passive range of motion preoperatively to maximize the success of the procedure. Neurectomies are mostly limited to the hip (anterior obturator neurectomy) or nonfunctional limbs because an irreparable lesion is created. 

Surgical criteria
The following guidelines maximize the benefit from surgery.
For procedures requiring active therapy postoperatively, the patient should be developmentally or cognitively at a level to allow adequate cooperation.
For procedures intended to improve gait, the patient should demonstrate enough trunk control to stand with minimal assistance. Deformities alone do not usually prevent walking.
Compliance with a preoperative program of exercises and night splinting minimizes the chance of recurrence. 
A stable supportive home or institutional setting should be present to ensure proper postoperative care and follow-up

Patient population 
Although most commonly used with children with CP, the procedures can be applied to children and adult with acquired spasticity as well. The specific cause of the CNS pathology is not often directly relevant to the selection of treatment. The cause, however, may be informative about a number of issues that play a role in treatment planning: 

Is the CNS pathology static / progressive?

The answer will clarify the functional prognosis both with and without intervention, and assist in the appropriate timing of surgery. 
Is the patient developmentally or cognitively able to cooperate and participate in pre- and postoperative treatment regimens? 
Are developmental changes to be expected that may influence the success and timing of surgery?
(Examples are bone growth and maturation of the hip joint.)

Surgical Approaches

• There are a number of approaches available in Orthopedic Surgery such as
  Conventional Orthopedic Surgery
• OSSCS
• SEMLLARS
• Ilizarov
• Percutaneous

Conventional Orthopedic Surgery
In routine orthopedic surgery, the orthopedic surgeon may use any one or a combination of the following procedure / technique

Muscle lengthening 
Surgically lengthening of the muscles used to relieve tightness in lower extremity or upper extremity

Tendon lengthening 
Surgically lengthening the tendons in case of contractures

Tendon transfer
Surgically transferring tendons to get proper alignment of the muscles

Tenotomy/Myotomy
 Surgically cutting of the tendon whereas myotomy involves cutting the muscle

Osteotomy 
Surgically repositioning bones at angles more conducive to healthy alignments

Arthrodesis 
Surgically fusing bones permanently in any joint

Mostly children with cerebral palsy require conventional orthopedic surgery only.

• Conventional surgeries may help these orthopedic conditions in children with spasticity
• Frank Scissoring- Hip adductor tightness
• Bent / flexed knees- Knee flexors tightness
• Toe walking / equines- Plantar flexors tightness
• Pronated mid arm- Mid arm pronator tightness
• Flexed hips- Hip flexors tightness

In a few cases, osteotomy is also included with soft tissue release to get optimal benefits. E.g.  recurvatum osteotomy 

OSSCS  (Orthopedic  Selected Spasticity Control Surgery)
OSSCS is an orthopedic procedure designed to control spasticity and athetosis
in cerebral palsy and allied disorders

Principle of OSSCS
The multiarticular muscles are lengthened or sectioned selectively.
The monoarticular muscles are preserved and facilitated.

The multiarticular muscles which have less antigravity activity are hyperactive in cerebral palsy. Therefore spasticity and athetotic movements can be controlled by releasing them selectively

The monoarticular muscles which have antigravity activity are carefully preserved. Hence, there is no loss of antigravity activity (muscle weakness)and no loss of sensation and stereognosis. There is also no increase in occurrence of dislocations and deformities.

Hyper tonicity of the neck, trunk, shoulder, elbow, forearm, wrist, thumb and fingers, hip, knee, and foot/ankle can all be controlled with the same generalized concept. All kinds of hyper tonicity (including spasticity and athetosis) are candidates for OSSCS. This control of spasticity provides promising results for orthopedic surgeons and also enriches the lives of people with cerebral palsy.

SEMLLARS (Single Event Multilevel Lever Arm restoration surgery)
SEMLLARS is a complex orthopedic technique where bony procedures are included with and without soft tissue release. More than one joint are taken care at the same procedure to get maximum alignment and minimum weakness.   

SEMLARS is practiced when a child with spasticity has multiples deformity with bony involvement like tibial torsion, femoral anteversion, hip dislocation etc

In  early days, when there were only conventional surgeries were available with children with cerebral palsy , the children needed to visit the orthopedic surgeon annually  to get surgery done.  It was called “Birth Day Syndrome” Due to SEMLLARS; the birthday syndrome is rarely observed.

Ilizarov Orthopedic Surgery
The Ilizarov apparatus is a type of external fixation used in orthopedic surgery to lengthen or reshape limb bones in children with cerebral palsy, spina bifida, leg length discrepancy and others. 

Ilizarov frames provide a versatile fixation system for the management of bony deformities, fractures and their complications. The frames give stability, soft tissue preservation, adjustability and functionality allowing bone to realise its full osteogenic potential.

Percutaneous
In this surgical method, the orthopedic surgeon makes an incision and does the required surgery. It requires lot of experience as the surgeon is not seeing the desired tendon to be cut. It has so many benefits as it does not require a big cut, lot of suturing and longer cast. The infection rate also drops down in this procedure.      

Conclusion- Our experiences
Surgery is an effective way to maximize function and simplify care in patients with spasticity / deformity. Accurate preoperative assessment and a well supervised postoperative program are critical in achieving these goals. To optimize surgical results, the assessment must be in the context of the patient's overall functional goals. The likelihood of further growth, recovery, or deterioration will shape plans for surgical intervention, as will the patient's prognosis for achieving important functional goals, both with and without surgery. In addition, the patient's history of prior conservative treatment will affect the level of surgical aggressiveness chosen.

Our experience with orthopedic surgery is very satisfactory. Every child who has undergone soft tissue releases has shown appreciable result in a short post surgical period. Generally, it requires 9-12 months to achieve optimal improvement in case of soft tissue release. Children who have undergone SEMLLARS are required to do post operative therapy for 12-18 months to harvest maximal result from the procedure.

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