Orthopaedic Surgeries and Physiotherapy in Cerebral Palsy

1. Orthopaedic Surgeries and Physiotherapy in Cerebral Palsy
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I. Spine/Neuromuscular Scoliosis
 Neuromuscular scoliosis is primarily caused by an imbalance between agonist and
antagonist muscles in the spine.
 Pelvic obliquity eventually develops owing to the scoliosis extending into the pelvis or
hip contracture, which affects the sitting posture.
 As the curve increases, the adolescent’s scoliosis may cause respiratory restriction, pain,
pressure sores, and increased difficulty with hygiene management.
Conservative management
 Is to improve sitting control and reduce or modify curve progression without the need
for surgical intervention.
 Back Braces for Scoliosis allows for more stability while sitting down. Use of
supportive bracing improves sitting balance and trunk support but lack evidence in
preventing scoliotic curve progression.
o Milwaukee brace. original scoliosis brace which is a CTLSO worn outside of
clothing.
o Boston brace. commonly prescribed brace today which is a TLSO fits like a
jacket
o Wilmington brace. Similar to the Boston brace but it closes in the front.
o Charleston bending brace. most prescribed nighttime TLSO brace.
 Wheelchair Modification: This is a very commonly recommended form of
nonsurgical treatment. The wheelchair can be customized to promote better posture.
 Physical Therapy: Specific exercises may help a patient with muscular imbalances
and it can improve motor functioning.
 Botulinum toxin injection or ITB provided some reduction in magnitude of the curve
in all patients.
Surgical management
 The pelvic obliquity and scoliosis are usually corrected by posterior spinal fusion.
 There is increased potential for improvements in respiratory function after surgery as
the lungs will generally have more volume for gas exchange and thoracic expansion
improves pulmonary issues,
 Complications post-surgery can be wounds, hardware failure, curve progression,
pancreatitis, and pseudoarthrosis.

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Post Op Rehab
 The patients are in ICU and electively ventilated for a period of 24-48 hours to restore
hemodynamic, electrolyte and fluid balance, postoperative pain, until they are
medically stable and optimized pulmonary recovery.
 Physiotherapy is offered to clear chest secretions, prevent, or treat respiratory infections
and rapidly mobilize the patients out of bed.
 The patients' wheelchair needs to be assessed and modified to accommodate for their
corrected spinal posture and seating balance after surgery.
 A reclining wheelchair can be used initially to provide better sitting comfort during the
immediate postoperative period and while a patient who has been fused distally to the
sacrum and the pelvis has difficulties to sit to 90°.
 No postoperative immobilization or external support is used.
II. Hip
A. Femoral Anteversion
 Increased femoral anteversion exaggerates hip internal rotation and can cause tripping
and falling when the toe of one shoe catches the opposite shoe during swing.
Surgical management
 A femoral derotation osteotomy with blade plate fixation, sometimes with medial
hamstring release is done.
Post Op Rehab
 Postsurgical management does not include cast or immobilization.
 PROM on postoperative day 1 or 2.
 The child is typically transferred out of bed into a wheelchair by day 2.
 Full weight bearing and assisted ambulation is expected by discharge, which occurs
between postoperative days 4 and 7.
 Physical therapy is directed toward increasing ROM and strengthening the hip muscles
for improvement in muscle balance.
 Functional training for movement and motor control.

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B. Hip Subluxation/Dislocation
 Children with and without CP are born with normal hips that are in an anteverted
position. Balanced muscle use and ambulation promotes normal hip alignment.
 In children with CP, ambulation is key to preventing hip subluxation.
 Superior and posterior direction subluxation is the most common pattern of hip
subluxation with adductor muscle spasticity being the primary cause.
Conservative treatment:
 Neurochemical spasticity interventions and passive muscle stretching of the adductors
and hip flexors.
 Intrathecal baclofen (ITB) can help decrease hip spasticity, but botulinum toxin is not
commonly used owing to the technical difficulty with injections.
 Proper positioning, correctly adjusted seating system, consistent standing may slow
progression.
Surgical management
Is divided into three basic categories:
(1) Soft tissue releases to halt early subluxation,
(2) Soft tissue and bony osteotomies to slow advancing subluxation due to femoral and
acetabular dysplasia. [In more severe cases Varus Derotation Osteotomies (VDROs), a
combination of muscle releases, reduction of the femoral head into the acetabulum, and
lastly, reconstruction of the acetabulum is done].
(3) Palliative surgery like THR for the painful, arthritic hip.
Post Op Rehab
 Postoperatively after hip soft tissue releases, allows for early weight bearing, stretching,
and functional strengthening and include muscle strengthening, Standing activities and
gait training.
 Common postoperative precautions include.
• no hip flexion past 90 degrees,
• limited hip rotation ROM, and
• no hip adduction past neutral.
• Advised early mobilization and weight bearing after surgery to prevent skin breakdown,
osteopenia, and weakness.

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C. Hip Adductor Contracture without Subluxation
• Indications for management of the hip adductors are:
• Improvement in a scissored gait
• Improved care of the perineum
Conservative management
• ITB injections are attempted first along with stretching and positioning and
strengthening of the hip abductors to promote muscle balance across the hip joint.
• The hip adductors release can be done to lengthen in isolation or with the iliopsoas
depending on the presentation of the child.
• Post surgically there is no period of immobilization and ROM/functional strengthening
can be started immediately.
D. Hip Flexor Contracture
• Hip flexion contractures forces to have excessive extension at the thoracolumbar
junction, and the knees remain flexed so that body orientation remains vertical.
Conservative management
• For passive stretching to be effective, the pelvis must be stabilized in either a supine or
a prone position.
• Prone positioning for activities, while gravity can assist in pulling the pelvis
• down toward the floor
• activation and strengthening of the hip extensors
Surgical intervention
• Complete cut/resection of the iliopsoas tendon or tendon transfer to the pelvis or hip
joint.
Post Op Rehab
• Physical therapy after surgery includes prone lying to maximize the lengthening into
hip extension and strengthening of the hip extensors and abductors.
III. Knee and Lower Leg
Knee Flexion Contracture
• This flexed knee or “crouched” gait usually includes decreased step length, increased
knee flexion in stance, decreased knee extension at terminal swing, increased hip

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flexion, and increased ankle dorsiflexion in stance. This crouched posture also causes
energy inefficiency during gait, because of continuous quadriceps firing.
• Persistent knee flexion eventually leads to contracture of the hamstrings and, in more
severe cases, knee joint capsule contracture and shortening of the sciatic nerve.
Conservative management
• Consistent hamstring stretching is often the first line of defence against contracture.
Lengthening tight posterior structures of the knee to prevent further deformity is the
goal of treatment. BTX-A injection with or without knee immobilizer use is another
conservative approach.
• Knee immobilizers can also be used during the day or while the child is sleeping without
Botox injections.
Surgical intervention
• There are three surgical interventions typically available to improve knee extension,
depending on the severity of contracture:
(1) hamstring lengthening,
(2) posterior knee capsulography with hamstring lengthening, and
(3) femoral extension osteotomy with hamstring lengthening.
Post Op Rehab
• Physical therapy begins postop day 1 with knee PROM, bed mobility, weight bearing
as tolerated, and family education of knee immobilizer use and stretching.
• Initially, knee immobilizer use is recommended 2 hours on, 2 hours off during the day
and on for the entire night but eventually weaned down to nighttime only.
• Hamstrings are stretched for 30 seconds three times a day starting postop day 2 and
continuing for at least 3 to 4 months after surgery.
• The outpatient PT should initially focus on improving hamstring flexibility,
active/passive knee extension range of motion (AROM/PROM), assisted standing with
immobilizers and/or AFOs, and strengthening of both knee extensors and flexors
(initiated approximately 6 weeks postop) for improved balance across the joint.
• The therapist must also emphasize ROM and strengthening exercises for the hip
musculature because the hamstrings cross the knee and hip joints.
• AFOs are often required to control dorsiflexion in standing and with ambulation.
• Gait training and balance training are in later phases of rehabilitation.

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• If posterior knee capsulotomy in addition to hamstring release is done Postoperative
management is more involved, with the knees splinted in extension for 12 to 18 hours
per day for 6 weeks and nighttime splinting in extension for up to 6 months.
Complication
• The most common complication of hamstring lengthening is recurrence of hamstring
contracture and return of the crouched/flexed knee gait pattern along with external tibial
torsion deformity and quadriceps weakness.
• Repeat hamstring lengthening are common due to this functional deterioration,
especially if the first surgery occurred in early childhood.10
• Sciatic nerve palsy is also a common complication due to nerves in the popliteal fossa
to become taut.
IV. Tibial Torsion
• In toeing or out-toeing due to internal or external tibial torsion are both relatively
common in CP and typically do not improve with maturity.
• Like femoral anteversion, internal tibial torsion can cause inefficient gait and tripping.
Surgical intervention
• Tibial osteotomy is the only effective surgery to correct internal and external tibial
torsion.
Post Op Rehab
 There are usually no precautions or weight-bearing limitations.
 The lower leg is often casted for 6 to 8 weeks.
 Rehabilitation is unrestricted after cast removal and should focus on improving walking
mechanics and balance.
 With a more normal foot progression angle, the demands on the plantar flexors and
dorsiflexors are changed, requiring specific strengthening to help these muscles handle
their new demands.
V. Ankle and Foot
A. Equinus Deformity
• The most common foot deformity in children with CP.
• Results from a muscular imbalance in which the plantar flexors of the ankle are five to
six times stronger than the dorsiflexors when there is spasticity around the ankle.

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• In ambulatory children, the hyperactive stretch reflex of the Plantar flexors is stimulated
during each stance phase, which is manifested as toe-walking, premature heel rise, or
premature ankle plantarflexion moment during gait.
• More severe involvement may have difficulty with foot placement on the pedals of the
wheelchair, assisted stand-pivot transfers, and donning of shoes causing a stretch to the
triceps surae triggering spastic equinus.
Conservative management
 Passive stretching, with care taken to “lock” the subtalar joint by slightly inverting the
ankle prior to stretching into dorsiflexion.
 Night-time splinting; and
 Strengthening of the dorsiflexors. A molded ankle-foot orthosis (MAFO) can help
maintain a neutral ankle position.
Serial casting protocol.
 Serial casting offers a conservative method to manage a shortened Achilles tendon, with
or without BTX-A injections.
 Typically, a cast is placed for 1 week with the joint set in the greatest range that does
not produce discomfort. The cast should be removed for joint mobility and
strengthening.
The next cast is placed for another week at the new comfortable end range.
This casting trial will continue for 2 to 6 weeks. Care must be exercised to lock the
subtalar joint while applying the cast to gain dorsiflexion of the ankle, to ensure
stretching of the gastrocnemius/ soleus group, and to prevent hypermobility of the
subtalar joint.
• Care should be taken that when an equinus ankle is forced into an orthosis/cast set at
90 degrees, there will be skin breakdown on the heel, or the foot will become
hypermobile in the joints distal to the calcaneus.
Surgical intervention
• Tendoachilles lengthening (TAL) and gastrocnemius recession are the two most
common.
• surgical procedures to treat equinus.
• TAL is most common and is indicated for contracture of both the gastrocnemius and
soleus muscle.

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• For normal soleus length and contracture of the gastrocnemius, a gastrocnemius
recession is done.
Postoperative care
 Short leg walking cast be worn for 4 to 6 weeks, set in neutral or slight dorsiflexion.
 Ambulatory children can tolerate full weight bearing in the walking casts within the
first few days after surgery.
 After removal of the cast, the child’s ankle will be quite weak owing to the surgery and
weeks of immobilization.
 Intermittent solid or articulating AFO use for 3 to 6 months after surgery is
recommended to help maintain postsurgical dorsiflexion gains and assist weight
bearing with optimal posture.
 Encourage active ankle movements when out of the orthosis to facilitate functional
strengthening and skill development.
 Strengthen the entire ankle, especially the dorsiflexors and plantar flexors.
 NMES or FES to activate the dorsiflexors.
 The long-term goal of rehabilitation should be optimal gait mechanics approximately 6
to 12 months after surgery.
Complication
• Overlengthening is a less common but a serious complication, resulting in excessive
dorsiflexion in midstance.
• This resulting “calcaneal gait” causes an increased crouched position, which further
stretches the plantar flexors and shortens the hip flexors and hamstrings.
• There is no therapeutic or surgical treatment that can “fix” overlengthening. Long-term
or permanent use of solid AFOs or GRAFOs is often necessary to prevent further
progression of crouched gait.
B. Plano valgus
 A plano valgus/ flat foot is a deformity caused by multiple factors including spasticity
(especially of the peroneals or plantar flexors), LE weakness, ligamentous laxity,
genetics, and altered biomechanics during standing and walking.
 This foot position causes increased pressure on the inside of the foot and great toe
during ambulation.

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 Flexible FF at first and can be corrected by reducing the subtalar joint and forefoot to a
neutral position with the ankle plantarflexed.
 Three situations contribute to more severe planovalgus deformity:
(1) spastic peroneal muscles that change the axis of rotation of the subtalar joint to a
more horizontal alignment and abduct the midfoot and forefoot.
(2) gastrocnemius/soleus contracture causing plantarflexion of the calcaneus; and
(3) persistent medial deviation of the neck of the talus.
Surgical intervention
 Requirement for surgical treatment is rare for flat feet in CP. There are several surgical
corrections commonly used:
(1) Lateral column lengthening (Evans Osteotomy): This involves osteotomy of then
calcaneus with bone graft used to maintain the osteotomy open after distraction
pushing the foot into a more supinated position.
(2) subtalar arthrodesis,
(3) triple arthrodesis.
Post op Rehab
 The child is placed in short leg walking casts until the osteotomy is healed, which takes
approximately 10 to 12 weeks. (Applicable for all three surgeries)
 An orthotic can be prescribed if necessary for further stability.
C. Varus Deformity
 Less common in children with CP and seen mostly in those with hemiplegia and
diplegia.
 It results from imbalance between weak peroneal muscles and spastic posterior or
anterior tibialis muscles.
 The varus foot is very unstable and at risk for inversion ankle sprain.
Conservative management
 The foot is best managed with splinting, stretching, and strengthening until about 8
years of age.
Surgical intervention
 Surgery is often delayed until about 8 years of age.
 The indication for surgery is a varus foot in stance or swing phase of gait.

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 Surgical procedures performed include lengthening or splitting and transferring of
either the posterior or anterior tibialis muscle.
Post op Rehab
 The foot is often casted for 4 weeks in a short leg walking cast in a neutral or slightly
dorsiflexed position.
 After the cast is removed, rehabilitation can be performed without restriction or an
orthosis.
 Therapeutic intervention should emphasize muscle reeducation, particularly when a
muscle has been transferred.
References
1. Beaman J, Kalisperis FR, Skomorucha KM. Chapter 5, The Infant and Child with
Cerebral Palsy. In: Pediatric Physical Therapy. 5th ed. Baltimore, Md: Lippincott
Williams & Wilkins, a Wolters Kluwer Business; 2015. p. 187–246.
2. Cloake T, Gardner A. The management of scoliosis in children with cerebral palsy: a
review. J Spine Surg. 2016;2(4):299-309. doi:10.21037/jss.2016.09.05
3. Tsirikos A. Development and treatment of spinal deformity in patients with cerebral
palsy. Indian J Orthop. 2010;44(2):148-158. doi:10.4103/0019-5413.62052