Cerebral palsy (CP) is the most common motor disability

Transcription

1 CLINICAL Single- Event Multilevel Surgery to Correct Movement Disorders in Children With Cerebral Palsy Jane M. Wick, BSN, RN; Jing Feng, PhD; Ellen Raney, MD; Michael Aiona, MD ABSTRACT Cerebral palsy (CP) is a common motor disability that may be congenital or acquired. Children with CP often have gait, balance, and posture abnormalities, some of which may be severe enough to interfere with safe ambulation or other activities of daily living. Nonsurgical and surgical interventions are part of the management plan for children with CP. Historically, surgeons addressed gait deviations individually and sequentially with single- level surgeries. However, computerized motion analysis and advances in orthopedic internal fixation devices have improved the outcomes for patients undergoing single- event multilevel surgery. This article provides perioperative RNs with a basic understanding of movement disorders that can be corrected with single-event multilevel surgery, the role of computerized motion analysis in making treatment decisions for ambulatory pediatric orthopedic patients with CP, and various treatment options for the movement disorders of children with CP. Key words: gait abnormality, cerebral palsy, motion analysis, single-event multilevel surgery. Cerebral palsy (CP) is the most common motor disability in childhood, affecting one in 323 children. 1 Cerebral palsy affects the individual s ability to control muscles and his or her capacity to maintain balance and posture. 2 It occurs as the result of either abnormal brain development or damage to the developing brain. In 85% to 90% of individuals with CP, the brain damage occurs before or during birth. Risk factors for congenital CP include low birth weight, premature birth, multiple births, infertility treatments, infection during pregnancy, and jaundice and kernicterus. 2 In acquired CP, the child is born without CP but acquires brain damage before the brain is fully developed. Acquired CP occurs in up to 10% of individuals diagnosed with CP. Causes for acquired CP include infections of the brain (eg, bacterial meningitis, viral encephalitis), injuries to the developing brain (eg, accidents, falls, near-drowning, abuse), or conditions that affect blood flow to the brain (eg, cerebrovascular accidents, clotting problems). 2 Cerebral palsy is classified according to the type of movement disorder involved (Sidebar 1). The inability to control movement leads to impairments such as muscle weakness, abnormal muscle tone, static or dynamic muscle contracture, abnormal joint alignment, or reduced range of motion. Consequently, people with CP may have abnormal gait patterns. Many of these impairments require both surgical and nonsurgical interventions 3,4 at various life stages. 516 AORN Journal AORN, Inc, 2018

2 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children Sidebar 1. Classification of Cerebral Palsy (CP) Cerebral palsy is classified according to the type of movement disorder involved. 1 Spastic CP affects approximately 80% of children with CP. Spastic CP involves increased muscle tone resulting in muscle stiffness or tightness. Spastic CP is further delineated as o diplegia (affecting mainly both legs), o hemiplegia (affecting mainly one side of the body), o triplegia (affecting three limbs, most commonly both legs and one arm), or o quadriplegia (the most severe form, affecting all four limbs, the trunk, and the face). Ataxic CP involves impaired coordination and balance. Dyskinetic CP involves uncontrollable movements with muscle tone that varies from too loose to too tight. Mixed CP is a combination of more than one type of CP. The most common type of mixed CP is spastic dyskinetic CP. The standard classification system for CP is the Gross Motor Function Classification System, 2 based on self- initiated movements. The five basic levels are as follows. Level I: Walks without restriction; has limitations in more advanced gross motor skills. Level II: Walks without assistive devices; has limitations walking outdoors and in the community. Level III: Walks with assistive mobility devices; has limitations walking outdoors and in the community. Level IV: Self-mobile with limitations; when outdoors or in the community, is transported or uses power mobility. Level V: Self-mobility is severely limited even with the use of assistive technology. REFERENCES 1. Basics about cerebral palsy. Centers for Disease Control and Prevention. cdc.gov/ncbddd/cp/facts.html. Updated April 18, Accessed July 5, Palisano R, Rosenbaum P, Bartlett D, Livingston M. Gross Motor Function Classification System Expanded and Revised. California Perinatal Quality Care Collaborative. cpqcc.org/sites/default/files/documents/ HRIF_QCI_Docs/GMFCS-ER.pdf. Accessed July 5, Patients with complex musculoskeletal problems may require multiple surgical procedures at different joints and muscles to correct gait deviations and help them participate in age- appropriate activities. Historically, surgeons addressed these gait deviations individually and sequentially by a series of single- level surgeries, with the most obvious problem being addressed first. An example that illustrates this process involves a child with an equinus contracture at the ankle that results in the child standing or walking on his toes. After the surgeon corrects the child s ankle contracture, it becomes apparent that the child s tight hamstrings are preventing his knees from straightening. Therefore, the surgeon performs another procedure to lengthen the child s hamstrings. This process continues each time the patient recovers from surgery and a new problem is identified. Mercer Rang, an eminent pediatric orthopedic surgeon, referred to this as the birthday syndrome because children would often be hospitalized on a yearly basis for orthopedic surgery. 5 One cause for these sequential and frequent surgeries was the inability of the surgeon to evaluate and quantify multilevel gait abnormalities objectively. Multiple factors have contributed to the evolution in gait abnormality management in patients with CP. The use of computerized motion analysis has allowed for a more complete and detailed identification of gait deviations, leading to the implementation of a more comprehensive treatment plan for patients with CP. Advances in orthopedic internal fixation devices improve the outcomes for patients undergoing single- event multilevel surgery (SEMLS) by allowing for more precise control of osteotomies, less casting, and earlier weight bearing and rehabilitation. The advantages of SEMLS include a single hospitalization, anesthetic, and rehabilitation period. In addition, using SEMLS can help to prevent secondary impairments such as muscle contractures that may occur when the surgeon addresses only a single problem. 6,7 Some experts consider SEMLS to be the standard of care for improving function and gait in ambulant children with AORN Journal 517

3 Wick et al November 2018, Vol. 108, No. 5 CP Common lower extremity soft tissue and bone procedures performed during SEMLS are illustrated in Figures 1 and 2. UNDERSTANDING THE GAIT CYCLE Gait patterns are analyzed in a gait cycle, which is defined as the duration between two consecutive heel strikes of the same limb. 11 A gait cycle includes the stance phase (ie, the first 60% of the gait cycle), when the foot contacts the ground, and the swing phase, when the foot is in the air (Figure 3). Analyzing gait data in terms of gait cycle allows for a comparison of gait patterns that have different gait velocities. Supplementary Video 1 shows the gait cycle; the green vector demonstrates the ground reaction force. COMPUTERIZED MOTION ANALYSIS The technology used to perform motion analysis varies. Visual gait analysis requires only a video recording device with the capability of replaying in slow motion the images of the patient taken from the front and side. Three- dimensional computerized motion analysis uses sophisticated hardware and software and multiple cameras to capture images of the patient from different directions. The motion capture system detects the markers worn by the patient and converts the patient s body segmental movements into three- dimensional digital data. Figure 1. Common lower extremity soft tissue procedures performed during single-event multilevel surgeries. Coronal view (a) and sagittal view (b). Red lines indicate procedures sites. Hip adductors are superimposed in the sagittal view. Illustration by Derek Tall, Production Manager, Pediatric Orthotics and Prosthetic Services, Shriners Hospitals for Children, Portland, OR. Figure 2. Common lower extremity bone procedures performed during single-event multilevel surgeries (coronal view). Red lines indicate procedures sites. Foot osteotomies are not included because foot procedures may vary and involve multiple bones. Illustration by Derek Tall, Production Manager, Pediatric Orthotics and Prosthetic Services, Shriners Hospitals for Children, Portland, OR. 518 AORN Journal

4 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children Figure 3. A gait cycle and its phases. A gait cycle begins with the heel strike of a single limb and ends with the next heel strike of the same limb. This shows the representative instantaneous position of the limbs corresponding to each phase of the gait cycle. The markers are aligned with joint axes of movement (eg, ankle joint axis) or placed on anatomical landmarks (eg, left or right anterior superior iliac). The biomedical engineer records the marker positions with the cameras, measures the ground reaction forces with force plates, and analyzes these using biomechanical models to calculate joint (eg, hip, knee, ankle) angles, moments, and power. Many gait models exist but, for routine clinical gait analysis, most motion analysis laboratories use the conventional gait model in which the lower limbs are represented as seven segments (ie, pelvis, upper legs, lower legs, feet). Shriners Hospitals for Children in San Francisco, California, 12 developed the conventional gait model. This model was later modified by the motion analysis laboratories at Newington Children s Hospital, Connecticut, and Helen Hayes Hospital, Haverstraw, New York. 13 The hip joint is modeled as a ball- and- socket joint with three degrees of freedom, while the ankle and knee joints are modeled as hinge joints with two degrees of freedom. The computer program allows motion capture to be depicted as multicolored stick figures that represent the marker connections or as walking skeletons that illustrate the bones and joints. Supplementary Video 2 is a tutorial video on a typical motion analysis laboratory, foot pressure system, surface electromyography, marker placement, computerized motion analysis, ground reaction force plates, and computer animation. Gait deviations are identified by comparing a patient s data with the normative values collected from a group of people with normal gaits (Table 1). The normative values are usually presented on graphs as a band with shading that depicts the mean value and one standard deviation (Supplementary Figure 1). The Motion Analysis Evaluation Although specific testing protocols may vary in each motion analysis laboratory, the basic components of computerized motion analysis remain consistent. A video of the child s gait is made from the front (coronal) and side (sagittal) as the child is walking. This provides video documentation of existing gait abnormalities and allows the formation of an overall impression. The video can be watched in slow motion and enlarged for closer views of body segments, allowing for a more methodical examination of the child s gait. Motion analysis includes a thorough clinical examination that focuses on the child s range of motion of joints, muscle strength and tone, motor control, and bony alignment. The clinical examination may provide insight to the anatomic abnormalities that lead to gait problem(s). This information must be combined with other components of the motion analysis to determine the underlying causes of the patient s gait abnormalities. After the video and clinical examination are complete, the patient is outfitted with reflective markers, and computerized motion analysis, which evaluates the kinematics and kinetics 14 of the patient s gait, begins (Supplementary Figures 2 and 3; Figure 4). Kinematics refers to the AORN Journal 519

5 Wick et al November 2018, Vol. 108, No. 5 Table 1. Gait Abnormalities in Children With Cerebral Palsy by Body Area Gait Abnormalities Characteristics Trunk Truncal sway Excessive truncal motion from side to side or front to back Hip Trendelenburg gait Scissoring Circumduction Knee Stiff knee Lateral trunk leans over the affected hip during stance phase Knees and thighs hit or cross the midline in a scissor- like movement Excessive hip abduction during swing phase Reduced arc of knee flexion- extension Figure 4. A motion capture system used for gait analysis that includes 10 infra- red cameras, a video camera, and five force plates. The space defined by the grids is the target volume of motion capture. Recurvatum Flexion Ankle/Foot Foot drop Toe- toe gait In- toeing Out- toeing Miscellaneous Antalgic gait Ataxic gait Dystonic gait Knee in hyperextension in midstance Knee does not fully extend in midstance or at terminal swing Inadequate dorsiflexion in swing resulting in toe- drag or tripping Heel never contacts ground Feet point inward Feet point outward Stance phase of affected side is shortened, usually because of pain Unsteady, uncoordinated gait with a wide base of support Irregular, jerky, and involuntary limb movement movement of joints (eg, hips, knees, ankles) and body segments (eg, trunk, femurs, tibias, feet). Kinematics includes spatial and temporal gait parameters. Computerized motion analysis laboratories have force plates embedded in the floor to evaluate the ground reaction forces, joint moments, and joint powers based on the kinematic calculations and ground reaction forces recorded during the computerized motion analysis. Kinetics provide discernment of the patient s functional weaknesses. Although muscle strength can be evaluated clinically, the findings may not correlate with actual muscle function occurring during the patient s gait. An abnormal bony alignment also may prevent muscles from working correctly, even if the muscles are strong. Areas where these force or kinetic measurements are used include the hip, knee, and ankle. Using the knee as an example, coronal plane kinetics calculated from gait analysis can help determine medial or lateral thrust of the knee caused by transverse plane deformities. This information can influence plans for clinical intervention. A patient s knee may appear to be in valgus (ie, angled outward from the midline), but the kinematics and kinetics may actually reveal a more complex set of problems, such as an internally rotated femur or an externally rotated tibia and flexed knee. Foot pressure data provide information about the loading pattern of the foot during walking and can quantify the distribution of force over the plantar surface of the foot. The findings from foot pressure data studies may influence the surgeon s choices for surgical correction for lengthening, transferring tendons, or performing osteotomies of the foot. The foot pressure data can be collected by a variety of means that include taping pressure sensors to the sole of the patient s foot, placing them in the patient s shoes, or incorporating them into a pressure sensor mat (Figure 5). Electromyography (EMG) uses surface or fine- wire electrodes to record the electrical activities (ie, timing and relative intensity) produced by the skeletal muscles during contractions (Supplementary Figure 4). Incorporating EMG in motion analysis has improved the treatment of patients with neuromuscular problems. 15 For example, information 520 AORN Journal

6 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children Table 2. Surgical and Nonsurgical Interventions for Managing Movement Disorders in Children With Cerebral Palsy Surgical Upper Extremity Biceps or brachialis lengthening Forearm, wrist, and finger tendon releases or transfers Rotational osteotomies Wrist and finger fusions First web-space deepening Thumb-in-palm correction Hip Adductor lengthening Proximal femoral osteotomy Psoas lengthening Acetabuloplasty Nonsurgical Tone Management Botulinum toxin to extremity muscles Baclofen (intrathecal) Baclofen pump insertion Assistive devices Orthotics Therapy Physical Occupational Knee Hamstring lengthening or transfer Rectus transfer or release Distal femoral shortening or extension osteotomy Patellar tendon advancement or realignment Knee capsule release Figure 5. A foot pressure study uses a pressure mat sensor (a). Foot pressure data are presented as two- dimensional contours using a color scale that indicates pressure. Polygons of various colors define the areas: heel, midfoot, first metatarsal head, second through fourth metatarsal head, fifth metatarsal head, and great toe. The black box in each polygon indicates where the highest peak pressure of the area shows. The black trajectory is the center of pressure trajectory as the weight shifts from the heel to the great toe during walking (b). A plot of peak pressure over time (c). The color of each curve corresponds to the color of the polygon that defines the area. kpa = kilopascals (kpa = 1,000 Newtons per square meter). from rectus femoris EMGs led to the development of surgical rectus femoris transfer procedures to correct stiff knee gait. Similarly, EMGs of the anterior and posterior tibialis muscles have been useful for planning surgical correction of varus foot deformities (ie, inward angulation of the foot) in patients with CP. 15 Information from EMG studies may be valuable for the surgeon making decisions Ankle Achilles tendon lengthening Calf lengthening (gastrocnemius or soleus) Tibial rotational osteotomy or wedge osteotomy (varus or valgus) Foot Anterior tibialis transfer Posterior medial or lateral release Posterior tibial lengthening or transfer Plantar fasciotomy Subtalar fusion Calcaneal neck lengthening or wedge osteotomy Midfoot wedge osteotomy Metatarsal osteotomy about SEMLS because certain muscle procedures may be selected based on the timing of muscle activity. Energy consumption testing can be used to measure gait efficiency and the energy required for the child to walk at a comfortable pace. This is done by measuring oxygen consumption, carbon dioxide production, heart rate, walking speed, or a combination of these. Comparing the patient s most recent energy consumption measurements with measurements from his or her previous studies also may AORN Journal 521

7 Wick et al November 2018, Vol. 108, No. 5 The Role of Motion Analysis in SEMLS Observational gait analysis can provide valuable information; however, it is subjective in nature, and the results depend on the observer s skill. Three- dimensional motion analysis provides more detailed quantitative information than observational gait analysis, leading to more accurate findings and identifying subtle deviations from normal that may be overlooked during observational analysis. This objective and quantitative data aids the interdisciplinary team in the decision- making process. Although team members opinions may differ on management, correctly defining the patient s gait problem is the essential first step. Figure 6. A procedure during single-event multilevel surgery showing the hamstrings being isolated before lengthening. serve as an outcome measurement for determining the effectiveness of surgical and nonsurgical interventions. Computerized motion analysis is a valuable component in a holistic approach to understanding gait deviations and their underlying causes (Supplementary Sidebar 1). The findings from motion analysis can then be combined with the physician s clinical examination and any applicable radiology study results to formulate an individual treatment plan that may include bracing (Supplementary Table 1 and Supplementary Figure 5), tone management, physical or occupational therapy, or surgery (Table 2 and Figures 6 and 7). Figure 7. A procedure during single-event multilevel surgery showing the Achilles tendon before a three- cut fractional lengthening of the tendon with planned incision sites marked. During gait analysis, a problem list is constructed using a systematic description of each joint deviation in each plane and phase of gait (ie, stance and swing). For example, the examiner may start in the sagittal plane by analyzing the foot contact pattern and then move to analysis of the knees, hips, and pelvis. After the sagittal plane problems have been identified, the examiner repeats the same sequence for the coronal and transverse planes. After a problem list has been created, the next step is to determine the potential causes of each deviation. Joints do not function in isolation. The movements of each joint are affected by the positions and motions of the other joints. For instance, patients with CP may walk with their knees bent because there are flexion contractures of either the knee or hip. However, the cause also could be that the quadriceps muscle is weak or the foot is not positioned correctly to stabilize the knee. The complexity of gait abnormalities varies and may require simple or in- depth analysis. The number and complexity of deviations increases the potential recommendations for treatment. One example of this is when a patient presents with a toe- toe pattern of foot contact in which the foot contacts the ground only on the forefoot and toes throughout the gait cycle. A normal foot contact pattern is from heel to toe. Toe walking is usually a sagittal plane problem at the ankle, but knee flexion in the stance phase also can cause this foot contact pattern. In this situation, lengthening the patient s calf is not indicated if the ankle motion is normal; instead, an intervention may be indicated at the knee. Inappropriate lengthening of a noncontracted calf may lead to excessive muscle weakness and a poor outcome for the patient. Quantitative gait analysis helps avoid this error by identifying the true ankle position, not just the foot contact pattern. Making treatment decisions based 522 AORN Journal

8 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children on observation alone can be misleading. Table 3 provides a list of team members and the role of each team member involved in motion analysis treatment planning. personnel in the discussion allows for effective planning related to necessary supplies, equipment, and implants, which helps avoid unanticipated events. INTERDISCIPLINARY TREATMENT PLANNING Team members at Shriners Hospitals for Children, Portland, Oregon, hold weekly interdisciplinary planning meetings to review patient motion analysis findings, discuss various treatment options, and make treatment recommendations. The surgeon discusses recommendations from the team meeting with the family during an outpatient clinic visit, and the family and physician decide on the course of treatment. If the treatment plan includes a surgical intervention, the medical staff members meet to review the proposed interventions one week before the scheduled surgery. All members of the clinical team, including nursing personnel, are encouraged to attend. The meeting attendees participate in interactive discussions of optimal patient treatments. At this time, the medical staff members discuss any procedure changes based on motion analysis reports or case review and the OR charge nurse notes any changes on the surgical schedule. The participation of perioperative Planning SEMLS Gait is a complex interaction involving at least three joints in three different planes, and developing a treatment plan can be challenging. Understanding the interplay between joints is necessary to distinguish primary versus secondary gait deviations. For example, because ankle function influences knee position in the sagittal plane, in some instances single joint management is sufficient, whereas in other instances both the ankle and knee need to be addressed. Evaluating the role of each gait deviation in relation to overall function is a vital step in the process of correcting gait abnormalities in children with CP. Not all deviations can or need to be normalized; however, significant deviations should be managed with the goal of improving the child s gait efficiency. Computerized motion analysis helps clinicians objectively and accurately understand gait abnormalities, which assists in treatment planning The information provided by the computerized motion analysis, a thorough physical examination, and clinical input from other team members Table 3. Motion Analysis Treatment Planning and Team Member Roles Team Member Role Physicians Motion analysis biomedical engineers Biomechanists, kinesiologists, motion analysis laboratory trained therapists Perioperative team members Orthotists, prosthetists Physical therapists, occupational therapists Case managers, social workers Refer appropriate patients for motion analysis Review the video and motion analysis report Postulate causes of abnormalities Make treatment recommendations Perform single-event multilevel surgery Set up motion analysis equipment and software Design biomechanical models Capture and analyze data Complete clinical examinations Perform patient preparation portions of motion analysis Identify gait abnormalities and generate motion analysis reports Present and interpret reports with physicians Prepare, perform, and assist with surgical interventions Design, fit, and monitor orthotics to correct alignment or provide support Complete clinical examinations Improve or restore mobility Help patients adapt to and live with injury or disability Coordinate patient and family care throughout process Manage discharge planning for equipment and intensive therapy Meet physical and emotional needs of patient and family Assist with financial planning AORN Journal 523

9 Wick et al November 2018, Vol. 108, No. 5 helps the surgeon formulate optimal treatment plans. Other factors considered by the interdisciplinary team during treatment planning include the patient s age, future growth potential, and risk of recurrence. A treatment plan also includes the scheduled postoperative management and physical or occupational therapy required to achieve the treatment goals. A case manager, social worker, and physical therapist are vital to coordinating the postoperative management of patients undergoing SEMLS. With the advent of stable internal fixation devices for osteotomies, improved tendon lengthening and transfer methods, and lightweight orthotics, SEMLS has become the gold standard for the care of patients with CP ,20 These advances make the rapid mobilization of the patient possible, reducing the recovery time ,20 Although SEMLS has become the preferred method, surgical procedures may be intentionally staged because the outcome of the initial surgery can affect the decisions regarding additional surgical interventions. The decision to stage surgeries also may be influenced by a need to mobilize a patient after soft tissue surgery versus immobilizing the patient after bone surgery. A patient may not have the strength or control to limit weight bearing on the surgical side after a lower extremity osteotomy. Regardless of the treatment plan that is implemented, motion analysis can assess the outcome of the interventions (Table 4) Postoperative motion analysis is usually conducted one year after the surgery. Performing SEMLS After the child s gait problems have been identified and the procedures to correct them have been chosen, the SEMLS is performed (Supplementary Sidebar 2). The surgeon obtains informed consent from the patient or Table 4. Expected Outcomes of Surgical Interventions to Correct Movement Disorders in Children With Cerebral Palsy Procedure Biceps or brachialis lengthening Arm tendon releases/transfer Forearm osteotomy Wrist and finger fusion First web space deepening Thumb- in- palm correction Selective dorsal rhizotomy Psoas lengthening Adductor lengthening Hamstring lengthening or transfer Femoral extension osteotomy Rectus femoris transfer Femoral rotation osteotomy Tibial rotational osteotomy Achilles tendon lengthening Gastrocnemius or soleus lengthening Anterior tibialis transfer Split anterior tibialis transfer Posterior tibialis lengthening Posterior tibialis transfer Split posterior tibialis transfer Plantar fascia release Subtalar fusion Triple arthrodesis Outcome Decrease elbow flexion, improve antecubital fossa hygiene Improve position of hand and forearm Improve hand s ability to be helper hand Allow for grasp of larger objects Prevent thumb from pushing objects out of the hand Decrease spasticity Decrease hip flexion in stance Decrease anterior pelvic tilt Decrease scissoring Increase knee extension in stance Improve stride length Increase knee arc Improve knee flexion timing during the swing phase Decrease abnormal leg rotation in gait Correct in-toeing or out-toeing Decrease abnormal tibial rotation Correct in-toeing or out-toeing Improve foot contact pattern in gait Improve heel contact pattern Improve foot prepositioning and brace tolerance Relieve pain from abnormal pressure Improve foot contact pattern 524 AORN Journal

10 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children patient s guardian. Notably, some procedures included on the informed consent form may be listed as possible or probable. Before beginning the surgery, the surgeon performs an examination with the patient under general anesthesia to verify clinical findings because some findings may change when the patient is under general anesthesia. Many patients have difficulty relaxing in the clinic, and young patients may be uncooperative during a clinical examination performed while they are awake and active. The decision as to whether the possible or probable procedures included on the consent form will be performed is based on the results of this examination. Each surgeon has his or her own preference for the sequence of performing a SEMLS. Whatever this preference may be, clear communication between the perioperative RN and other members of the surgical team is of utmost importance. Some children with CP have upper extremity as well as lower extremity involvement. In procedures during which an upper extremity surgeon and a lower extremity surgeon are both performing SEMLS procedures at the same time, two surgical teams are required. When multiple procedures are performed on multiple limbs, the soft tissue procedures are generally performed first followed by the osteotomy procedures to minimize any risk to the stability of bone fixation. Conversely, sometimes the patient s underlying bone malformation must be corrected before tension can be adjusted on transferred tendons. Other factors that may determine procedural order include the patient s position and whether a tourniquet is used. EXEMPLAR 1: PATIENT M UNDERGOING UNILATERAL SEMLS Patient M was born at 33 weeks gestational age. Because of respiratory difficulties, he remained in the neonatal intensive care unit for several weeks after birth. His parents grew concerned when he failed to meet developmental milestones, and at 14 months of age, patient M was diagnosed with spastic triplegic CP affecting predominantly his left side with some involvement of his right lower extremity. He began walking at two years of age. At age five, the spasticity in his left leg was treated with botulinum toxin injections to the left gastrocnemius and hamstrings. When he was eight years old, patient M underwent surgeries for a left leg Achilles tendon and posterior tibialis lengthening, and a botulinum toxin injection to his left hamstring. After the surgeries, patient M continued to experience balance control problems, though he was able to walk, run, and play. Patient M s parents would like him to have better balance and be able to ambulate with a more normal- appearing gait. At age nine years and five months, his physician referred him for a computerized motion analysis for progressive gait abnormalities including flexed knee gait and in- toeing. Because in- toeing may be caused by rotational problems at the pelvis, femur, tibia, foot, or a combination, a computerized motion analysis will help to identify the primary cause of patient M s in- toeing. Preoperative Motion Analysis Key findings and recommendations from patient M s preoperative motion analysis included the following. Increased knee flexion with stiff knee gait, left. Kinematics showed increased knee flexion at initial contact and midstance, resulting from hamstring tightness. His left knee flexion was reduced significantly in the swing phase, indicating a stiff knee gait, which in his case is caused by tightness of the rectus femoris. Patient M s physical examination revealed mild hip and knee flexion contractures; there also was tightness in his straight leg raise, popliteal angle, and prone knee flexion. In-toeing, left greater than right. Kinematics demonstrated left femoral rotation that remained significantly internal to normal throughout the gait cycle; the right femoral rotation was close to normal. His tibial rotation was at the internal end of the normal band bilaterally. His foot progression angles were markedly internal to normal on the left and slightly internal to normal on the right. Patient M s physical examination showed more internal than external hip rotation bilaterally, confirming medial femoral rotation with more severe asymmetry on the left side than on the right. His transmalleolar axes and foot-thigh angles were slightly internal to normal bilaterally, indicating only mild tibial torsion. Motion analysis helped to determine that the primary cause of patient M s in-toeing was internal femoral rotation, left greater than right. Based on patient M s preoperative motion analysis, the interdisciplinary team recommended femoral derotational AORN Journal 525

11 Wick et al November 2018, Vol. 108, No. 5 osteotomy, hamstring lengthening, and rectus femoris to semitendinosus tendon transfer on the left side. The surgeon discussed the recommendations with the family, who elected to proceed with the surgical procedures. Patient M s SEMLS was performed six months after his motion analysis. SEMLS Procedures After patient M was under general anesthesia, the surgeon performed a thorough preoperative examination to evaluate his range of motion. Patient M was then positioned prone and the surgeon identified and lengthened the medial and lateral sides of the hamstring tendons. The surgeon then identified the semitendinosus tendon and stripped the tendon from its superior attachment using a tendon stripper. Patient M was then repositioned supine and the surgeon performed a distal femoral osteotomy with plate and screw fixation, achieving 35 degrees of external rotation. The surgeon mobilized and transferred the rectus musculature to the medial aspect of the wound, wove the semitendinosus tendon through the rectus tendon, and secured it with suture. At the completion of patient M s SEMLS surgery, an orthotist placed patient M in a hinged knee brace. Patient M required three days of hospitalization for pain management and resumption of safe mobilization. He did not bear weight on his left leg for five weeks, after which he began working on range of motion, standing, and gait training. The surgeon counseled patient M and his family that it could take up to a year before he demonstrated a consistent improvement in gait. Postoperative Motion Analysis Key findings and recommendations from patient M s 16- month postoperative motion analysis included the following. Increased knee extension in midstance, left. Kinematics show increased knee extension in midstance. His physical examination shows improvements in straight leg raise and popliteal angle. Increased arc of knee motion, left. Kinematics shows significantly increased arc of knee motion. His physical examination shows increased prone knee flexion. Decreased internal femoral rotation, left. Kinematics shows that his femoral rotation and foot progression angles have shifted from internal rotation preoperatively to within the normal band postoperatively. His physical examination shows increased range of external femoral rotation. Although no surgery was performed on patient M s foot, the foot pressure analysis shows improvements in loading, pressure distribution, and center of pressure trajectory. All of the surgical goals for patient M were met. He showed marked improvements in kinematics, foot pressure, and physical examination measurements. The family is satisfied with the outcome of the surgeries, and they are pleased with patient M s improved gait (Supplementary Figure 6 and Supplementary Video 3). EXEMPLAR 2: PATIENT S BILATERAL SEMLS Patient S is an 11- year- old girl who walks with braces. She has diplegic spastic CP, Gross Motor Function Classification System level II. She was born at 38 weeks gestation via cesarean delivery for fetal bradycardia, and weighed 7 lb 10 oz. There were no complications at the time of her birth, and she was discharged home three days after delivery. At the age of three months, patient S was hospitalized with pneumonia. She was intubated for three weeks in a pediatric intensive care unit. Patient S was able to sit up at eight months. At nine months, when she started standing and walking while holding onto furniture, her parents noted that she seemed to be dragging her right foot. Patient S was subsequently assessed by a pediatrician as well as a pediatric neurologist, who referred her for magnetic resonance imaging of the brain and thoracolumbar spine, which were found to be normal. She was given a possible diagnosis of CP and was fitted with a right ankle foot orthosis to correct her right foot drag. At age 23 months, patient S was referred to Shriners Hospitals for Children, Portland, Oregon, because of bilateral toe- walking gait. Until eight years of age, patient S underwent treatment with physical therapy, a series of botulinum toxin injections to her gastrocnemius and hamstring muscles, and serial casting. When she was eight years old, her calf muscles developed contractures as a consequence of her growth and spasticity. Because of changes in her walking pattern, her physician referred patient S for 526 AORN Journal

12 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children a computerized motion analysis, which resulted in a recommendation from the interdisciplinary team for bilateral calf lengthening procedures to address her contractures. Patient S underwent surgery without complication. Her outcome was quantified with a one- year postoperative motion analysis that demonstrated improved range of dorsiflexion and improved ankle sagittal kinematics with no adverse effects. Patient S transitioned to a posterior leaf spring ankle foot orthosis. Her mobility was acceptable until the age of 11 years when she began to experience unsteadiness and falls after a period of rapid growth. Her physician performed observational gait analysis and identified bilateral in- toeing with equinus and persistent knee flexion because of hamstring tightness. To quantify these gait abnormalities and assist in treatment planning, her physician referred patient S for a computerized motion analysis, which was performed when she was 11 years, 11 months old. Preoperative Motion Analysis Key findings and recommendations from patient S s preoperative motion analysis included the following. Increased knee flexion in gait, right greater than left. Kinematics showed increased knee flexion in stance with a reduced total arc of motion, right side greater than left. Her physical examination showed passive full knee extension. Her straight leg raise and popliteal angles revealed hamstring tightness. The interdisciplinary team recommended bilateral hamstring lengthening procedures. Increased plantarflexion, right greater than left. Kinematics showed increased plantarflexion throughout gait, right side greater than left. Her foot pressure study showed a toe-toe contact pattern with no pressure on the heel and midfoot. Patient S s physical examination showed plantarflexion contractures with knee flexion and with knee extension, right side greater than the left. The team recommended bilateral calf lengthening procedures to address both the soleus and gastrocnemius muscles. Internal femoral rotation, bilateral; external tibial rotation, right. On the right, kinematics showed slight internal femoral rotation and external tibial rotation, with foot progression angles close to normal. On the left, kinematics showed that her femoral rotation, tibial rotation, and foot progression angles were significantly internal to normal throughout the gait cycle. Coronal plane kinetics showed increased medial knee thrust on the right, which was of concern because thrust can cause strain and lead to arthritis. Her physical examination showed an internal prone hip rotation arc with reduced range of external rotation bilaterally. Transmalleolar axes and thigh-foot angles were external to normal on the right side. The team recommended bilateral distal femoral derotational osteotomies and a right tibial derotational osteotomy. SEMLS Procedures To improve the alignment of her lower extremities and the efficiency of her gait, patient S underwent multilevel bony and soft tissue procedures soon after the motion analysis. After patient S was under general anesthesia, she was positioned prone and the surgeon performed bilateral hamstring semitendinosus and gracilis tenotomies, right semimembranosus lengthening, right Z-lengthening of her Achilles tendon, and left gastrocnemius recession. Patient S was then repositioned supine and the surgeon performed right distal fibular osteotomy to allow rotation of the tibia, right distal tibial rotational osteotomy with plate and screw fixation to obtain correction of 25 degrees of internal rotation of the distal segment of the tibia, right distal femoral osteotomy in which the distal fragment of femur was externally rotated 25 degrees and secured using plate and screw fixation, and left femoral derotation osteotomy achieving 30 degrees of external rotation secured using plate and screw fixation. After completing the surgical procedures, the surgeon applied below- the- knee fiberglass casts to patient S s lower extremities with the ankles in a neutrally dorsiflexed position. The orthotist then applied bilateral knee immobilizers. AORN Journal 527

13 Wick et al November 2018, Vol. 108, No. 5 Key Takeaways Patients with cerebral palsy may require multiple surgical and nonsurgical interventions to correct their gait abnormalities and enable them to participate in age-appropriate activities. The advantages of single-event multilevel surgery (SEMLS) include a single hospitalization, anesthetic, and rehabilitation period. Computerized motion analysis uses sophisticated hardware and software and multiple cameras to capture images of the patient from different directions and to convert the patient s body segmental movements into three-dimensional data. Many patients undergoing SEMLS provide consent for multiple probable or possible procedures on multiple limbs. The anticipated surgical procedures may change after the surgeon performs a physical and fluoroscopic examination with the patient under general anesthesia. Therefore, a comprehensive time out with all members of the surgical team is essential. The surgical team must use extreme vigilance when verifying correct placement of the pneumatic tourniquet cuff because SEMLS may involve exsanguination of multiple limbs and multiple inflations and deflations. Postoperative Motion Analysis Twelve months after her SEMLS, patient S and her parents were pleased with the overall results of the procedures, and she underwent a postoperative gait study. Key findings and recommendations from the postoperative motion analysis included the following. Decreased knee flexion in gait, bilateral. On the right, kinematics continues to show mild increased knee flexion in stance and a decreased arc of motion, which are similar to her preoperative measurements; however, she has improved knee extension in midstance when she wears bilateral posterior leaf spring ankle foot orthoses. On the left, patient S s knee flexion is significantly improved compared with her preoperative measurements and she has an improved arc of motion. Her postoperative physical examination measurements show improved straight leg raise and popliteal angles. Plantigrade gait, bilateral. Ankle sagittal kinematics show significant improvement with decreased plantarflexion, left side greater than right. On the right side, she has some residual plantarflexion in midstance that is likely used to assist knee extension. She has a mild foot drop at the end of swing bilaterally; this is corrected with her bilateral posterior leaf spring ankle foot orthoses. Her preoperative foot pressure study shows a toe-toe contact pattern bilaterally. Postoperatively, her contact pattern is foot-flat bilaterally with reduced heel pressure. Patient S s physical examination shows improved range of dorsiflexion postoperatively. The team recommended that she continue to use the bilateral posterior leaf spring ankle foot orthoses to control her foot drop in swing. Decreased internal femoral rotation, bilateral. Kinematics shows postoperative femoral rotations are within the normal range. Her knee thrust has improved compared with the coronal plane kinetics seen preoperatively. Her corresponding foot progression angles are on the internal edge of norms bilaterally. Patient S s physical examination shows her hip rotations are close to normal. Decreased external tibial rotation, right. Kinematics shows improvement of tibial rotation from external to within the normal range. Her foot progression angle is near the normal range. Patient S s physical examination shows postoperative correction of the transmalleolar axis. All of the SEMLS surgical goals for patient S were met. Although some kinematic abnormalities are still present, such as mild persistent knee flexion on the right side, her gait velocity has improved and is more efficient. After reviewing preoperative and postoperative motion analyses, the interdisciplinary team believed that additional surgical correction would provide minimal functional improvements. Because her postoperative motion analysis 528 AORN Journal

14 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children shows greater efficiency and velocity in gait, no additional surgical procedures are indicated (Supplementary Figure 7 and Supplementary Video 4). CONCLUSION Single- event multilevel surgeries are complex procedures for surgical teams, requiring organization, skill, and attention to details. Extensive planning is involved in the care and treatment of gait dysfunction and movement disorders in patients with CP, and performing multiple surgeries in a single event is an intricate task. Perioperative RNs must become familiar with the evolving technology that is increasingly a part of perioperative nursing practice. Motion analysis plays an important role in surgical decision making. Computerized motion analysis is an excellent example of evidence- based care with clinical applications that play an increasing role in the care of surgical patients. Like other evolving technology, the use of computerized motion analysis depends on clinicians having the aptitude and inclination to apply the technology correctly in clinical settings. Computerized motion analysis provides objective and quantitative data that improves our understanding of the etiology of gait abnormalities and provides valuable data for making decisions before SEMLS as well as augments and optimizes treatment plans for the movement disorders of patients with CP. Perioperative RNs play an important and challenging role in the complex care of these patients. Acknowledgments: The authors thank the following individuals from Shriners Hospitals for Children, Portland, OR: Harlan Pine, graphic arts specialist, for his assistance with supporting photos, videos, and figures used to illustrate key points in the article; Erin Bompiani PT, DPT, PCS, Motion Analysis Center physical therapist, for her contribution to general content of the article and Supplementary Table 1; Rosemary Pierce, PT, Motion Analysis Center physical therapist, for her contribution to Table 4; Todd DeWees, CPO, staff orthotist and prosthetist at Pediatric Orthotics and Prosthetics Services, for his contribution to Supplementary Table 1; Derek Tall, production manager at Pediatric Orthotics and Prosthetics Services, for developing the graphic art drawings for Figures 1 and 2; Krister Freese, MD, orthopedic surgeon, for providing the upper extremity portions of Table 2 and Table 4; Patrick Do, Motion Analysis Center engineer, for providing data collection and analysis; Elizabeth Blair, RN, Denice Cummings, RN, and Diane Holmes, RN, perioperative RNs, for participating in SEMLS procedures, proofreading the article, and providing feedback to the authors before submission; Karen Fraser- Collins, RN, and her daughter, Iona Collins, for participating as the normal patient depicted in Supplementary Figures 2 and 4 and Video 2; and Steve Davis, the bear dancer in Video 2, for allowing us to use his demonstration of motion analysis animation. The authors also thank patient M and patient S and their families for allowing us to use their motion analysis laboratory videos and data as exemplar cases. SUPPORTING INFORMATION Additional information may be found online in the supporting information tab for this article. REFERENCES 1. Christensen D, Van Naarden Braun K, Doernberg NS, et al. Prevalence of cerebral palsy, co- occurring autism spectrum disorders and motor functioning. Autism and Developmental Disabilities Monitoring Network, USA, Dev Med Child Neurol. 2014;56(1): Basics about cerebral palsy. Centers for Disease Control and Prevention. ncbddd/cp/facts.html. Accessed July 5, Narayanan UG. Management of children with ambulatory cerebral palsy: an evidence- based review. J Pediatr Orthop. 2012;32(suppl 2):S172 S Feng J, Wick J, Bompiani E, Aiona M. Applications of gait analysis in pediatric orthopaedics. Curr Orthop Pract. 2016;27(4): Rang M. Cerebral palsy. In: Lovell and Winter s Pediatric Orthopedics. 2nd ed. Philadelphia, PA: JB Lippincott; 1986: Thomason P, Selber P, Graham HK. Single event multilevel surgery in children with bilateral spastic cerebral palsy: a 5- year prospective cohort study. Gait Posture. 2013;37(1): Davis RB III, Õunpuu S, DeLuca PA, Romness MJ. Clinical gait analysis and its role in treatment decision-making. August 14, Medscape. [subscription required]. Accessed July 5, Wren TAL, Otsuka NY, Bowen RE, et al. Influence of gait analysis on decision- making for lower extremity AORN Journal 529

15 Wick et al November 2018, Vol. 108, No. 5 orthopaedic surgery: baseline data from a randomized controlled trial. Gait Posture. 2011;34(3): Wren TAL, Elihu KJ, Mansour S, et al. Differences in implementation of gait analysis recommendations based on affiliation with a gait laboratory. Gait Posture. 2013;37(2): Wren TA, Otsuka NY, Bowen RE, et al. Outcomes of lower extremity orthopedic surgery in ambulatory children with cerebral palsy with and without gait analysis: results of a randomized controlled trial. Gait Posture. 2013;38(2): Gage JR, DeLuca PA, Renshaw TS. Gait analysis: principle and applications with emphasis on its use in cerebral palsy. Instr Course Lect. 1996; 45: Sutherland DH, Hagy JL. Measurement of gait movements from motion picture film. J Bone Joint Surg Am. 1972;54(4): Baker RJ, Rodda J. All you ever wanted to know about the Conventional Gait Model but were afraid to ask. University of Salford, Manchester. ac.uk/41444/. Accessed July 5, Sutherland DH. The evolution of clinical gait analysis, part III: kinetics and energy assessment. Gait Posture. 2005;21(4): Sutherland DH. The evolution of clinical gait analysis, part I: kinesiological EMG. Gait Posture. 2001;14(1): DeLuca PA, Davis RB III, 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): Ferrari A, Brunner R, Faccioli S, Reverberi S, Benedetti MG. Gait analysis contribution to problems identification and surgical planning in CP patients: an agreement study. Eur J Phys Rehabil Med. 2015;51(1): Rasmussen HM, Pedersen NW, Overgaard S, et al. The use of instrumented gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomized controlled trial protocol. BMC Pediatr. 2015;15: org/ /s Wren TAL, Gorton GE III, Ounpuu S, Tucker CA. Efficacy of clinical gait analysis: a systematic review. Gait Posture. 2011;34(2): Bischof FM. Single event multilevel surgery in cerebral palsy: a review of the literature. SA Orthop J. 2010;9(1): Aiona M, Do KP, Feng J, Jabur M. Comparison of rectus femoris transfer surgery done concomitant with hamstring lengthening or delayed in patients with cerebral palsy. J Pediatr Orthop. 2017;37(2): De Mattos C, Do KP, Pierce R, Feng J, Aiona M, Sussman M. Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow- up. J Child Orthop. 2014;8(6): Haumont T, Church C, Hager S, et al. Flexed- knee gait in children with cerebral palsy: a 10- year follow- up study. J Child Orthop. 2013;7(5): Dreher T, Wolf SI, Heitzmann D, et al. Long- term outcome of femoral derotation osteotomy in children with spastic diplegia. Gait Posture. 2012;36(3): Dreher T, Wolf SI, Maier M, et al. Long- term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff- knee gait in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012;94(19):e142(1 10). JBJS.K Dreher T, Buccoliero T, Wolf SI, et al. Long- term results after gastrocnemius- soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy. J Bone Joint Surg Am. 2012;94(7): Firth GB, Passmore E, Sangeux M, et al. 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): Khouri N, Desailly E. Rectus femoris transfer in multilevel surgery: technical details and gait outcome assessment in cerebral palsy patients. Orthop Traumatol Surg Res. 2013;99(3): Sung KH, Chung CY, Lee KM, et al. Long- term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait. Gait Posture. 2013;37(4): Terjesen T, Lofterød B, Skaaret I. Gait improvement surgery in ambulatory children with diplegic cerebral palsy: a 5- year follow- up study of 34 children. Acta Orthop. 2015;86(4): AORN Journal

16 November 2018, Vol. 108, No. 5 Correcting Movement Disorders in Children Jane M. Wick, BSN, RN, is a perioperative RN at Shriners Hospitals for Children in Portland, OR. Ms Wick has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Jing Feng, PhD, is the manager of the Motion Analysis Center at Shriners Hospitals for Children in Portland, OR. Dr Feng has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Ellen Raney, MD, is a pediatric orthopedic surgeon at Shriners Hospitals for Children in Portland, OR. Dr Raney has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Michael Aiona, MD, is the chief of staff and a pediatric orthopedic surgeon at Shriners Hospitals for Children in Portland, OR. Dr Aiona has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. AORN CONTINUING EDUCATION FOR INDIVIDUALS AORN can help you keep up with the latest perioperative practices to maintain your license or certification requirements. Earn contact hours through AORN Journal continuing education (CE) articles, prerecorded webinars, tool kits, and online courses. AORN Journal CE articles cover a variety of perioperative topics that can help you prepare for recertification, renew your license, or just stay up-to-date to improve your own practice. AORN members receive free access to Journal CE. AORN webinars present the latest clinical and managerial issues, perioperative news, and best practices to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures. AORN tool kits address critical patient safety issues and help perioperative professionals implement evidence-based practices. Each tool kit contains a wealth of resources, including customizable policies and procedures, education slideshows, videos, posters, guides, and references. AORN online courses are designed to educate perioperative nurses on a variety of topics that go beyond the standards of Periop 101. Further your education online with topics that are essential to promoting safety and optimal outcomes for patients, such as ambulatory infection prevention, safe administration of moderate sedation, and pre- and postoperative care in the ambulatory surgery center. AORN Journal 531