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Rectus Femoris Transfer

Planning

B

Preoperative Plan

1

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Army-Navy or Sofield retractors
  • a tonsil clamp (or similar, long clamp) to bring the semitendinosus into the anterior incision.

2

Room setup and equipment

  • standard OR table
  • radiolucent table is needed if bone surgery is being done as part of SEMLS

3

Patient positioning

  • supine

Technique

D

Skin Incision and superficial dissection

1

Make the longitudinal anterior incision

  • make a 4 to 5 cm longitudinal incision over the distal anterior thigh
  • the distal extent of the incision should at the proximal tip of the patella

2

Dissect down to expose the quadriceps tendon.

  • dissecting scissors and/or electrocautery are used to expose the quadriceps tendon
  • the medial and lateral borders of the tendon are exposed

3

Make the longitudinal posterior incision

  • make a 4-5 cm longitudinal incision in the distal third of the posterior thigh
  • identify the semitendinosus and incise the overlying fascia to expose the musculotendinous junction
E

Deep Dissection

P

1

Develop plane between the rectus femoris and vastus intermedius tendons

  • it is easiest to separate the rectus from the remainder of the quadriceps tendon proximally, usually 4-5 cm proximal to the patella
  • incise longitudinally for a length of 1-2 cm deep along the medial (or lateral) border of the quadriceps tendon 4 to 5 cm proximal to the patella
  • find the plane between the rectus femoris and the vastus intermedius
  • develop the interval with a freer elevator and/or manual dissection with a finger
Pearls
  • The plane between the rectus and the vastus intermedius separates easily with blunt dissection.

2

Dissect and mobilize the rectus

  • use a freer elevator to penetrate the extensor mechanism immediately adjacent to the lateral border of the rectus femoris
  • use blunt dissection to free the lateral border of the rectus
  • the rectus should be separated from the vastus intermedius as distally as possible (to ~ 1 cm proximal to the patella) using blunt dissection
  • place a 2-0 nonabsorbable whipstitch in the rectus stump
Pearls
  • Dissection should proceed from proximal to distal to ensure staying in the correct plane.
F

Transection of the Rectus and the Semitendinosus

P

1

Transect the rectus

  • transect the rectus 1 cm proximal to the patella while leaving the vastus intermedius below it intact
  • free the tendon from all underlying attachments after placement of a whip stitch using a size 2-0 nonabsorbable braided suture
  • pull the tendon distally and free the tendon from any soft tissue attachments proximally both medially and laterally.
  • after these soft tissue attachments are released, the rectus should have an excursion of at least 1.5 to 2 cm when manual traction is applied
Pearls
  • To avoid entering the knee joint, make sure that the rectus tendon is easily visualized and separate from underlying tissue.

2

Transect the semitendinosus

  • place a right-angle retractor around the semitendinosus and transect the tendon proximal to the musculotendinous junction
  • place a non-absorbable 2-0 whipstitch in the tendon stump and free the tendon distally
G

Rectus Transfer

P

1

Identify and incise the intermuscular septum

  • use small rakes to retract the medial skin flap
  • dissection is deep to the fascia overlying the vastus medialis
  • retract the vastus medialis
  • identify and incise the intermuscular septum using cautery
  • make a large 3-4 cm window in the septum to keep the rectus transfer from becoming tethered.
  • the semitendinosus tendon stump is brought into the anterior compartment through this window
  • this is facilitated by use of a tonsil (or similar) clamp to grab the whip stitch in the semitendinosus stump
Pearls
  • Right angle retractors (such as Sofield retractors) can facilitate blunt dissection of the vastus medialis off the septum.

2

Complete the transfer

  • complete the transfer under some tension, while still allowing full knee extension
H

Wound Closure

1

Deep closure

  • simple, interrupted 2-0 absorbable sutures are used in the subcutaneous tissue

2

Superficial closure

  • a running 3-0 nondyed absorbable monoftilament suture is used on the skin
  • a longer-lasting monofilament (e.g. PDS) is used for the anterior incision to minimize the risks of dehiscence and spreading of the scar

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion
  • check prone rectus (Duncan-Ely) test for rectus spasticity
  • observe the patient's gait
  • identify medical co-morbidities that might impact surgical treatment

2

Screen studies (including gait study) to identify and contraindications for surgery

  • the indications for rectus transfer on the gait study: 1) stiff-knee gait and 2) an overactive rectus in swing phase
  • results of distal rectus femoris transfer are best in GMFCS I and II patients

3

Perform operative consent

  • Describe potential complications of surgery including
  • Crouch gait
  • Failure to improve knee flexion
  • Wound dehiscence, scar spreading or infection
L

Perioperative Inpatient Management

1

Write comprehensive admission orders if the rectus transfer is part of SEMLS

  • Advance diet as tolerated
  • IV fluids
  • Pain control
  • diazepam often helps significantly with spasms
  • physical therapy for gait training if not contraindicated by other, simultaneous, procedures
  • wound management
  • not typically needed in the hospital
  • dressings may be changed POD 2 if the patient has not been discharged

2

Discharges patient appropriately

  • pain control
  • diazepam is often helpful for spasms in the first 5-7 days post-op
  • schedule follow up in 1-2 weeks
  • wound care
  • dressings may be removed by family 7 days post-op
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • signs and symptoms
  • stiff-knee gait and tripping in GMFCS I and II children may indicate that a rectus transfer could be considered.
  • physical exam
  • assesses range of motion and prone rectus (Ducan-Ely) test
  • performs a visual observation of the child's gait
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • computerized gait analysis, when available, is reviewed
  • no radiographs or blood tests are indicated

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 1-2 Week Postoperative Visit

  • physical therapy is started, if not contraindicated by other, simultaneous, procedures
  • diagnose and management of early complications
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • increases frequency and intensity of physical therapy and home program if the child is slow to progress post-operatively
O

Complex Patient Care

1

Develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • this typically only occurs in the child undergoing SEMLS.
 

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