Orthopaedic Surgery for Neuromuscular Gait Dysfunction

There are many surgical techniques that might be used to treat gait dysfunction in children with neurologic disorders. Children with neurologic disorders involving spasticity, movement disorders, dystonia, flaccid paralysis, and a wide range of diagnoses can experience gait dysfunction. Gait dysfunction is caused by a problem in the brain and results in balance issues, movement disorders, sensory disturbances, and altered muscle tone, all of which can lead to tendon/muscle contractures and bony deformities.

If our team feels that without surgery your child’s gait will continue to worsen and, eventually, your child will no longer be able to walk, the team will recommend surgery. Surgery is performed by a multidisciplinary care team that includes specialists from the Neuromuscular Orthopaedic Program, which is part of the Division of Orthopaedics at Children’s Hospital of Philadelphia (CHOP). This team is made up of nationally and internationally recognized physicians and surgeons who specialize in the treatment of cerebral palsy, spina bifida, spinal muscular atrophy (SMA), muscular dystrophy, Charcot-Marie-Tooth and other neuromuscular disorders.

A child may require multiple surgical procedures to correct all of their gait problems. At CHOP, we perform all of the surgical procedures a child needs to correct their gait problems at one time. This approach results in a shorter rehab period than multiple surgeries, but is a harder recovery. Two separate surgical teams are often needed to perform surgery in one day.

To determine which surgical procedures are best for your child, our team of highly specialized pediatric orthopaedic surgeons performs a comprehensive evaluation that may include:

• A medical history
• Physical exam
• Gait analysis
• X-rays (in some cases)

During a pre-operative consultation, the team will discuss all of the various surgeries your child may require. Then, on the day of surgery, your child will undergo a final physical exam under anesthesia. The surgeon may alter the planned surgical approach based on the results of this examination. The surgeon will speak with you if any additional procedures are thought to be necessary after this exam.

Your child may require one or more of the following specific surgical procedures:

• Hip osteotomy — If the thigh (femur) bone is internally rotated too far, the surgeon will reorient the thigh bone to derotate and seat the bone more appropriately in the socket of the pelvis. This procedure can also help when children’s hips rotate inappropriately when walking.
• Hip soft tissue surgery — If your child is experiencing spasticity and muscle contracture in the muscles around the hip, the muscles can be selectively lengthened during surgery.
• Knee osteotomy — Knee flexion deformity occurs over time and can result in a “fixed” contracture. The surgeon will straighten the femur and hold it in place with a plate and screws. The bone can be turned slightly and the surgeon can correct some knock knee or bow leggedness at the same time. 
• Knee soft tissue surgery — The gait study may suggest the need for a re-orientation of one of the muscles in the knee to the back of the leg to avoid “stiff knee” gait  or to re-tension the muscle to prevent recurrence of the crouching. The surgeon will transfer the patellar ligament using a piece of bone or soft tissue and secure with strong stitches or screws.
• Tibia osteotomy — If the tibia (shin bone) is rotated out similar to how the thigh bone is rotated in, it can produce a knock knee appearance. If the thigh bones are rotated out and the shin bones not rotated in, it can cause out-toeing (turning out) of the leg. The surgeon will cut the tibia bone and turn it inward to match the kneecap and fix it with a plate and screws.
• Leg soft tissue surgery — If the heel cords are tight, this can lead to toe walking, excessive pronation (flattening) of the feet, and difficulty with brace tolerance. The surgeon will lengthen the heel cord or the calf muscle to bring the foot into a more neutral position.
• Foot bony surgery — If the foot is not a rigid lever for push-off and acceptance of weight when the foot lands, the surgeon will cut the bone and alter the shape of the foot so it is in a more normal position.
• Soft tissue foot surgery — The gait study may show abnormal firing of muscles. This can result in a dynamic deformity of the foot that could lead to brace intolerance. The surgeon will address this by transferring muscles to make the forces on the foot (the lever) more normal during walking.

CHOP is continually top-ranked by U.S. News and World Report as one of the best children’s hospitals for orthopaedic care in the United States. CHOP’s experienced professionals, excellent facilities, and commitment to safety make it a top choice for families locally, nationally and internationally.

While surgery to correct gait dysfunction is done rarely at most hospitals, it is common at CHOP. Our orthopaedic surgeons, anesthesiologists, pain experts, nurses and therapists guide several kids each week through surgery and recovery. If necessary, we can consult world experts right here at CHOP in any pediatric medical specialty.

Our operating facilities, intensive care units, recovery rooms and patient rooms are state of the art.

Your child will have a pre-operative clinic visit one to two weeks prior to surgery.

This consultation will include:

• A review of the surgical procedure by your surgeon and members of our anesthesia team
• A review of your child’s medical history, any medications they are taking, and results from their physical examination with the nurse practitioner or physician’s assistant
• A review of surgical complications. Although unusual, complications can include infection, vessel or nerve injury, failure of the bone to heal, extra bone formation at the surgical site, and other medical complications requiring readmission.
• Time to answer any questions you may have regarding the surgery, the hospitalization, and the postsurgical rehabilitation

On the day of the procedure, your child will be given calming medication and be transported to the operating room. In the operating room, your child will be gently put to sleep and IVs will be placed. While under anesthesia, your child will receive a catheter and, in most cases, an epidural is placed for pain control.

The surgical team will then perform the procedure. All incisions will be closed with absorbable sutures.

There is a very large, comfortable family lounge where you can spend the hours during surgery. Members of our family services team will check in on you several times throughout the day to give you updates on the progress of surgery. Once surgery is over, the surgeon will meet with you to discuss the surgery and answer any questions you have.

After surgery, your child will be transported to the post-anesthesia care unit (PACU), where they will be monitored by highly specialized nurses. Once your child has been stabilized in the PACU, Family Services will bring you to see your child. 

A typical length of stay in the hospital after surgery is two to five days. Your child will be able to go home once they:

• Are able to sit comfortably
• Have good pain control by mouth or G tube
• Have a bowel movement

Although your child will be splinted in a slightly flexed position immediately after surgery, the surgeon may decide to cast your child’s legs straight prior to discharge and measure for new braces under sedation or in the cast room.

Before you leave the hospital, the floor nurse practitioner or resident will give you important information regarding medications, incisional care, and who to call with questions. Some children will require ambulance transportation which will be set up by case management.

Some children will require hospital beds, commodes, walkers or home nursing care. Our case managers will assist with these things while you are still in the hospital. If you think you will have difficulty caring for your child at home, be sure to talk to case management while at the hospital.

After four to six weeks at home, your child will return to the outpatient Orthopaedic clinic for a follow-up appointment and will be admitted to inpatient rehabilitation at CHOP Seashore House for one to four weeks. Typically, a child will be out of school for four to six weeks, although some scholastic activity is available as part of inpatient rehabilitation.

Following inpatient therapy, your child will undergo six to nine months of outpatient therapy. Therapy is an important part of the post-operative recovery and should be an important consideration pre-operatively. CHOP therapists may be available in your area who are familiar with this condition, procedure, and the post-operative recovery. Find a list of CHOP’s Specialty Care Centers near you.