Skip to main content
SpringerLink
Log in

Multilevel Orthopedic Surgery for Patients with Cerebral Palsy

  • Chapter
  • First Online:
Orthopedic Care of Patients with Cerebral Palsy

  • 600 Accesses

Abstract

Single event multilevel surgery (SEMLS) refers to the concept of performing multiple orthopedic procedures during one operative event so as to limit the number of hospitalizations and life-altering disruptions for patients and caregivers. Instrumented three-dimensional motion analysis techniques have advanced our understanding of gait deviations in individuals with cerebral palsy so that surgeons can be more confident in treatment decision-making. By observing children during their younger years, health-care providers can document functional issues and help target treatment to specific problems. Nonoperative treatments such as stretching, bracing, orthotics, therapies, medications, and tone management procedures offer options for many individuals, but surgery is often recommended for specific gait deviations. Ideally, combining as many of these surgical procedures and rehabilitation periods into single events can limit psychosocial and financial costs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Rang M. Lovell and Winter’s pediatric orthopaedics. Philadelphia: JB Lippincott; 1990.

    Google Scholar 

  2. Perry J. Gait analysis: normal and pathological function. 1st ed. Thorofare: Slack; 1992.

    Google Scholar 

  3. Norlin R, Tkaczuk H. One-session surgery for correction of lower extremity deformities in children with cerebral palsy. J Pediatr Orthop. 1985;5(2):208–11.

    Article  CAS  PubMed  Google Scholar 

  4. Bleck E. Goals, treatment and management. In: Orthopaedic management in cerebral palsy. London: MacKeith Press; 1987. p. 142–212.

    Google Scholar 

  5. Bell K, Ounpuu S, DeLuca PA, Romness MJ. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop. 2002;22(5):677–82.

    PubMed  Google Scholar 

  6. Johnson DC, Damiano DL, Abel MF. The evolution of gait in childhood and adolescent cerebral palsy. J Pediatr Orthop. 1997;17(3):392–6.

    CAS  PubMed  Google Scholar 

  7. Lee SY, Kwon SS, Chung CY, Lee KM, Sung KH, Kim S, Park MS. Influence of surgery involving tendons around the knee joint on ankle motion during gait in patients with cerebral palsy. BMC Musculoskelet Disord. 2018;19(1):82.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ferrari A, Brunner R, Faccioli S, Reverberi S, Benedeiit MG. Gait analysis contribution to problems identification and surgical planning in CP patients: an agreement study. Eur J Phys Rehabil Med. 2015;51(1):39–48.

    CAS  PubMed  Google Scholar 

  9. Kay RM, Dennis S, Rethlefsen S, Reynolds RA, Skaggs DL, Tolo VT. The effect of preoperative gait analysis on orthopaedic decision making. Clin Orthop Relat Res. 2000;372:217–22.

    Article  Google Scholar 

  10. Moon D, Esquenazi A. Instrumented gait analysis: a tool in the treatment of spastic gait dysfunction. JBJS Rev. 2016;4(6):1.

    Article  Google Scholar 

  11. Wren TA, Elihu KJ, Mansour S, Rethelfsen SA, Ryan DD, Smith ML, Kay RM. Differences in implementation of gait analysis recommendations based on affiliation with a gait laboratory. Gait Posture. 2013;37(2):206–9.

    Article  PubMed  Google Scholar 

  12. Wren TA, Otsuka NY, Bowen RE, Scaduto AA, Chan LS, Sheng M, Hara R, Kay RM. Influence of gait analysis on decision-making for lower extremity orthopaedic surgery: baseline data from a randomized controlled trial. Gait Posture. 2011;34(3):364–9.

    Article  PubMed  Google Scholar 

  13. Lofterod B, Terjesen T. Results of treatment when orthopaedic surgeons follow gait-analysis recommendations in children with CP. Dev Med Child Neurol. 2008;50(7):503–9.

    Article  PubMed  Google Scholar 

  14. Lofterod B, Terjesen T, Skaaret I, Huse AB, Jahnsen R. Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients. Acta Orthop. 2007;78(1):74–80.

    Article  PubMed  Google Scholar 

  15. Cook RE, Schneider I, Hazlewood ME, Hillman SJ, Robb JE. Gait analysis alters decision-making in cerebral palsy. J Pediatr Orthop. 2003;23(3):292–5.

    PubMed  Google Scholar 

  16. DeLuca PA, Davis RB 3rd, Ounpuu S, Rose S, Sirkin R. Alterations in surgical decision making in patients with cerebral palsy based on three-dimensional gait analysis. J Pediatr Orthop. 1997;17(5):608–14.

    Article  CAS  PubMed  Google Scholar 

  17. Gage J. An overview of treatment. In: Gages J, editor. The treatment of gait problems in cerebral palsy. London: MacKeith Press; 2004. p. 238–44.

    Google Scholar 

  18. Rosenbaum PL, Palisano RJ, Bartlett DJ, Galuppi BE, Russell DJ. Development of the gross motor function classification system for cerebral palsy. Dev Med Child Neurol. 2008;50(4):249–53.

    Article  PubMed  Google Scholar 

  19. Hanna SE, Rosenbaum PL, Bartlett DJ, Palisano RJ, Walter SD, Avery L, Russell DJ. Stability and decline in gross motor function among children and youth with cerebral palsy aged 2 to 21 years. Dev Med Child Neurol. 2009;51(4):295–302.

    Article  PubMed  Google Scholar 

  20. Park MS, Chung CY, Lee KM, Lee SH, Choi IH, Cho TJ, Yoo WJ, Kim KH. Issues of concern before single event multilevel surgery in patients with cerebral palsy. J Pediatr Orthop. 2010;30(5):489–95.

    Article  PubMed  Google Scholar 

  21. Gorton GE 3rd, Abel MF, Oeffinger DJ, Bagley A, Rogers SP, Damiano D, Romness M, Tylkowski C. A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009;29(8):903–9.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Fabry G, Liu XC, Molenaers G. Gait pattern in patients with spastic diplegia cerebral palsy who underwent staged operations. J Pediatr Orthop. 1999;8(1):33–8.

    CAS  Google Scholar 

  23. Mahmudov V, Gunay H, Kucuk L, Coskunol E, Calis AF. Comparison of single event vs multiple event soft tissue surgeries in the lower extremities with cerebral palsy. J Orthop. 2015;12(Suppl 2):S171–5.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Dreher T, Thomason P, Svehlik M, Doderlein L, Wolf SI, Putz C, Uehlein O, Chia K, Steinwender G, Sangeux M, Graham HK. Long-term development of gait after multilevel surgery in children with cerebral palsy: a multicenter cohort study. Dev Med Child Neurol. 2018;60(1):88–93.

    Article  PubMed  Google Scholar 

  25. Ounpuu S, Bell K, DeLuca P. The “birthday syndrome” vs. the single event multilevel surgical approach: a comparison of financial costs. Presented at 13th annual meeting of the Gait and Clinical Movement Analysis Society. Richmond; April 2008.

    Google Scholar 

  26. Wren TA, Kalisvaart MM, Ghatan CE, Rethlefsen SA, Hara R, Sheng M, Chan LS, Kay RM. Effects of preoperative gait analysis on costs and amount of surgery. J Pediatr Orthop. 2009;29(6):558–63.

    Article  PubMed  Google Scholar 

  27. Lehtonen K, Maenpaa H, Piirainen A. Does single-event multilevel surgery enhance physical functioning in the real-life environment in children and adolescents with cerebral palsy (CP)?: patient perceptions five years after surgery. Gait Posture. 2015;41(2):448–53.

    Article  PubMed  Google Scholar 

  28. Himpens E, Franki I, Geerts D, Tack R, Van der Looven R, Van den Broeck C. Quality of life in youngsters with cerebral palsy after single-event multilevel surgery. Eur J Paediatr Neurol. 2013;17(4):401–6.

    Article  CAS  PubMed  Google Scholar 

  29. Lee KM, Chung CY, Park MS, Lee SH, Choi IH, Cho TJ, Yoo WJ. Level of improvement determined by PODCI is related to parental satisfaction after single-event multilevel surgery in children with cerebral palsy. J Pediatr Orthop. 2010;30(4):396–402.

    Article  PubMed  Google Scholar 

  30. Lee SH, Chung CY, Park MS, Choi IH, Cho TJ, Yoo WJ, Lee KM. Parental satisfaction after single-event multilevel surgery in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009;29(4):398–401.

    Article  PubMed  Google Scholar 

  31. Park MS, Chung CY, Lee SH, Choi IH, Cho TJ, Yoo WJ, Lee KM. Issues of concern after a single-event multilevel surgery in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009;29(7):765–70.

    Article  PubMed  Google Scholar 

  32. Cuomo AV, Gamradt SC, Kim CO, Pirpiris M, Gates PE, McCarthy JJ, Otsuka NY. Health-related quality of life outcomes improve after multilevel surgery in ambulatory children with cerebral palsy. J Pediatr Orthop. 2007;27(6):653–7.

    Article  PubMed  Google Scholar 

  33. Dequeker G, Van Campenhout A, Feys H, Molenaers G. Evolution of self-care and functional mobility after single-event multilevel surgery in children and adolescents with spastic diplegia cerebral palsy. Dev Med Child Neurol. 2018;60(5):505–12.

    Article  PubMed  Google Scholar 

  34. Yu S, Rethlefsen SA, Wren TA, Kay RM. Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review. J Pediatr Orthop. 2015;35(3):285–9.

    Article  PubMed  Google Scholar 

  35. Rutz E, Tirosh O, Thomason P, Barg A, Graham HK. Stability of the Gross Motor Function Classification System after single-event multilevel surgery in children with cerebral palsy. Dev Med Child Neurol. 2012;54(12):1109–13.

    Article  PubMed  Google Scholar 

  36. Harvey A, Rosenbaum P, Hanna S, Yousefi-Nooraie R, Graham HK. Longitudinal changes in mobility following single-event multilevel surgery in ambulatory children with cerebral palsy. J Rehabil Med. 2012;44:137–43.

    Article  PubMed  Google Scholar 

  37. Godwin EM, Spero CR, Nof L, Rosenthal RR, Echternach JL. The gross motor function classification system for cerebral palsy and single-event multilevel surgery: is there a relationship between level of function and intervention over time? J Pediatr Orthop. 2009;29(8):910–5.

    Article  PubMed  Google Scholar 

  38. Thomason P, Baker R, Dodd K, Taylor N, Selber P, Wolfe R, Graham HK. Single-event multilevel surgery in children with spastic diplegia: a pilot randomized controlled trial. J Bone Joint Surg Am. 2011;93(5):451–60.

    Article  PubMed  Google Scholar 

  39. Thomason P, Selber P, Grahan HK. Single event multilevel surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. Gait Posture. 2013;37(1):23–8.

    Article  PubMed  Google Scholar 

  40. Rutz E, Baker R, Tirosh O, Brunner R. Are results after single-event multilevel surgery in cerebral palsy durable. Clin Orthop Relat Res. 2013;471(3):1028–38.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Gough M, Eve LC, Robinson RO, Shortland AP. Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history. Dev Med Child Neurol. 2004;46(2):91–7.

    Article  PubMed  Google Scholar 

  42. Rutz E, Donath S, Tirosh O, Graham HK, Baker R. Explaining the variability improvements in gait quality as a result of single event multi-level surgery in cerebral palsy. Gait Posture. 2013;38(3):455–60.

    Article  PubMed  Google Scholar 

  43. Saraph V, Zwick EB, Auner C, Schneider F, Stenwender G, Linhart W. Gait improvement surgery in diplegic children: how long do the improvements last? J Pediatr Orthop. 2005;25(3):263–7.

    Article  PubMed  Google Scholar 

  44. Edwards TA, Theologis T, Wright J. Predictors affecting outcome after single-event multilevel surgery in children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2018;60(12):1201–8.

    Article  PubMed  Google Scholar 

  45. Svehlik M, Stenwender G, Kraus T, Saraph V, Lehmann T, Linhart WE, Zwick EB. The influence of age at single-event multilevel surgery on the outcome in children with cerebral palsy who walk with flexed knee gait. Dev Med Child Neurol. 2011;53(8):730–5.

    Article  PubMed  Google Scholar 

  46. Svehlik M, Steinwender G, Lehmann T, Kraus T. Predictors of outcome after single-event multilevel surgery in children with cerebral palsy: a retrospective ten-year follow-up study. Bone Joint J. 2016;98-B(2):278–81.

    Article  CAS  PubMed  Google Scholar 

  47. Adolfsen SE, Ounpuu S, Bell KJ, DeLuca PA. Kinematic and kinetic outcomes after identical multilevel soft tissue surgery in children with cerebral palsy. J Pediatr Orthop. 2007;27(6):658–67.

    Article  PubMed  Google Scholar 

  48. Niklasch M, Wolf SI, Klotz MC, Geisbusch A, Brunner R, Doderlein L, Dreher T. Factors associated with recurrence after femoral derotation osteotomy in cerebral palsy. Gait Posture. 2015;42(4):460–5.

    Article  CAS  PubMed  Google Scholar 

  49. Ounpuu S, Solomito M, Bell K, Pierz K. Long-term outcomes of external femoral derotation osteotomies in children with cerebral palsy. Gait Posture. 2017;56:82–8.

    Article  PubMed  Google Scholar 

  50. Ounpuu S, Solomito M, Bell K, DeLuca P, Pierz K. Long-term outcomes after multilevel surgery including rectus femoris, hamstring, and gastrocnemius procedures in children with cerebral palsy. Gait Posture. 2015;42(3):365–72.

    Article  PubMed  Google Scholar 

  51. Thompson N, Stebbins J, Seniorou M, Wainwright AM, Newham DJ, Theologis TN. The use of minimally invasive techniques in multi-level surgery for children with cerebral palsy: preliminary results. J Bone Joint Surg Br. 2010;92(10):1442–8.

    Article  CAS  PubMed  Google Scholar 

  52. Gannotti ME, Gorton GE 3rd, Nahorniak MT, Masso PD, Landry B, Lyman J, Sawicki R, Hagedorn K, Ross E, Warner J. Postoperative gait velocity and mean knee flexion in stance of ambulatory children with spastic diplegia four years or more after multilevel surgery. J Pediatr Orthop. 2007;27(4):451–6.

    Article  PubMed  Google Scholar 

  53. Firth GB, Passmore E, Sangeux M, Thomason P, Rodda J, Donath S, Selber P, Graham HK. Multilevel surgery for equinus gait in children with spastic diplegic cerebral palsy: medium-term follow-up with gait analysis. J Bone Joint Surg Am. 2013;95(10):931–8.

    Article  PubMed  Google Scholar 

  54. Saglam Y, Ekin Akalan N, Temelli Y, Kuchimov S. Femoral derotation osteotomy with multi-level soft tissue procedures in children with cerebral palsy: does it improve gait quality? J Child Orthop. 2016;10(1):41–8.

    Article  PubMed  Google Scholar 

  55. Novacheck TF, Stout JL, Gage JR, Schwartz MH. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique. J Bone Joint Surg Am. 2009;91(Suppl 2):271–86.

    Article  PubMed  Google Scholar 

  56. Sousa TC, Nazareth A, Rethelfsen SA, Meuske NM, Wren TA, Kay RM. Rectus femoris transfer surgery worsens crouch gait in children with cerebral palsy. J Pediatr Orthop. 2019;39:466–71.

    Article  PubMed  Google Scholar 

  57. Klotz MCM, Krautwurst BK, Hirsch K, Niklasch M, Maier MW, Wolf SI, Dreher T. Does additional patella tendon shortening influence the effects of multilevel surgery to correct flexed knee gait in cerebral palsy: a randomized controlled trial. Gait Posture. 2018;60:217–24.

    Article  CAS  PubMed  Google Scholar 

  58. Klotz MCM, Hirsch K, Keitzmann D, Maier MW, Hagmann S, Dreher T. Distal femoral extension and shortening osteotomy as part of multilevel surgery in children with cerebral palsy. World J Pediatr. 2017;13(4):353–9.

    Article  PubMed  Google Scholar 

  59. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am. 2006;88(12):2653–64.

    Article  CAS  PubMed  Google Scholar 

  60. McGinley JL, Dobson F, Ganeshalingham R, Shore BJ, Rutz E, Graham HK. Single-event multilevel surgery for children with cerebral palsy: a systemic review. Dev Med Child Neurol. 2012;54(2):117–28.

    Article  PubMed  Google Scholar 

  61. Lamberts RP, Burger M, du Toit J, Langerak NG. A systematic review of the effects of single-event multilevel surgery on gait parameters in children with spastic cerebral palsy. PLoS One. 2016;11(10):e0162686.

    Article  CAS  Google Scholar 

  62. Thomason P, Selber P, Graham HK. Single event multi-level surgery in children with bilateral spastic cerebral palsy: a 5 yr prospective cohort study. Gait Posture. 2013;37(1):23–8.

    Article  PubMed  Google Scholar 

  63. Gannotti ME, Gorton GE III, Nahorniak MT, Masso PD. Walking abilities of young adults with cerebral palsy: changes after multilevel surgery and adolescence. Gait Posture. 2010;32(1):46–52.

    Article  PubMed  Google Scholar 

  64. Putz C, Döderlein L, Mertens EM, Wolf SI, Gantz S, Braatz F, Dreher T. Multilevel surgery in adults with cerebral palsy. Bone Joint J. 2010;98-B(2):282–8.

    Article  Google Scholar 

  65. Putz C, Wolf SI, Mertens EM, Geisbusch A, Gantz S, Braatz F, Doderline L, Dreher T. Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy. Bone Joint J. 2017;99-B(9):1256–64.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors wish to acknowledge Sylvia Õunpuu, MSc for her assistance preparing the figures in this chapter.

Author information

Authors and Affiliations

  1. Center for Motion Analysis, Department of Orthopedic Surgery, Connecticut Children’s Medical Center, University of Connecticut School of Medicine, Farmington, CT, USA

    Kristan Pierz & M. Wade Shrader

  2. Division of Cerebral Palsy, Department of Orthopedic Surgery, Nemours A.I. DuPont Hospital for Children, Wilmington, DE, USA

    Kristan Pierz & M. Wade Shrader

Authors
  1. Kristan Pierz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Wade Shrader
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kristan Pierz .

Editor information

Editors and Affiliations

  1. Department of Orthopedics, Helen DeVos Children’s Hospital, Grand Rapids, MI, USA

    Philip D. Nowicki

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Pierz, K., Shrader, M.W. (2020). Multilevel Orthopedic Surgery for Patients with Cerebral Palsy. In: Nowicki, P. (eds) Orthopedic Care of Patients with Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-030-46574-2_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-46574-2_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-46573-5

  • Online ISBN: 978-3-030-46574-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation