A Intermediate Evaluation and Management 1 Obtains focused history and physical history signs and symptoms physical exam visual gait assessment recognizes factors that could predict complications or poor outcome 2 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 3 Postop: 3-4 Week Postoperative Visit wound check remove the knee immobilizer during the day use a knee immobilizer at night for 6-12 months diagnose and management of early complications B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment post-operative neuropraxia requires allowing the knee to be placed in a flexed position to take tension off the peroneal nerve as nerve recovery ensues, the knee is progressively extended for increasing amounts of time C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion, including popliteal angle observe the child walking for visual gait assessment note that if the child toe walks when in AFO braces, the knees are flexed in stance phase identify medical co-morbidities that might impact surgical treatment 2 Review gait analysis, if available. 3 Screen medical studies to identify contraindications to surgery 4 Orders appropriate initial laboratory studies 5 Perform operative consent describe complications of surgery including genu recurvatum -- much more common after combined medial and lateral hamstring lengthening than with isolated medial hamstring lengthening. recurrence neuropraxia
E 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 F Room Preparation 1 Surgical instrumentation right angle clamp. right angle retractors (e.g. Sofield or Army-Navy) 2 Room setup and equipment standard OR table (Radiolucent if bone procedures being performed also) 3 Patient positioning supine G Skin Incision 1 Make the incision make a 3-5 cm midline incision in the distal third of the posterior thigh. dissection is carried out to expose the semitendinosus medially. H Semitendinosus Lengthening 1 Dissect sharply medially to expose the deep fascia. dissect sharply with electrocautery or dissecting scissors. 2 Isolate the semitendinosus the semitendinosus is noted to be the most superficial posteromedial structure and is tendinous distally sharp dissection is used (with electrocautery or dissecting scissors) to expose the deep fascia. incise the deep fascia with tenotomy scissors 3 Place a right angle clamp around the semitendinosus tendon after isolating the semitendinosus, place a right angle clamp around the semitendinosus tendon from lateral to medial lateral to medial placement minimizes the risk of neurovascular damage 4 Transect the semitendinosus the semitendinosus tendon is typically transected at the musculotendinous junction with electrocautery however, if a distal rectus femoris transfer is also being done, the transection is proximal to the musculotendinous junction (to allow enough tendon for the transfer) I Semimembranosus lengthening 1 Isolate the semimembranosus incise the fascia over the semimembranosus with tenotomy scissors and isolate the semimembranosus as far anteromedially as possible. 2 Incise the aponeurosis cut the aponeurosis transversely with a 15 blade at 1 or 2 levels leave the underlying muscle undisturbed when 2 cuts are made, the proximal cut is done first so that tissue is still on tension when the distal cut is made 3 Test the release bring the knee into full extension with the ipsilateral hip extended if the knee comes easily to full extension, lateral hamstring lengthening is not needed do NOT check a popliteal angle as this appears to increase the risk of post-operative peroneal neuropraxia J Biceps Femoris Lengthening 1 Isolate the biceps femoris sharply dissect laterally (with electocautery or dissecting scissors) through the same midline incision and expose the deep fascia over the biceps femoris incise the deep fascia with dissecting scissors to fully expose the biceps femoris 2 Incise the aponeurotic band incise the fascia over the biceps with a 15 blade identify and isolate the discreet apneurotic band that is located laterally on the biceps transect this band at 1 or 2 levels while leaving the underlying muscle intact K Wound Closure 1 Sucbcutaneous closure is with simple sutures of 2-0 absorbable suture 2 Subcuticular closure is with an undyed, running 3-0 absorbable monofilament.
O Perioperative Inpatient Management 1 Write comprehensive discharge orders knee immobilizers for 16-18 hours daily for 3 weeks. full weight bearing allowed immediately start physical therapy within 1 week pain control diazepam usually very helpful for painful spasms for 5-7 days family can remove dressings in 3-5 days follow-up appointment in 1-2 weeks R Complex Patient Care 1 Develop a comprehensive preoperative plan that includes options based on intraoperative findings, especially in the setting of single event multilevel surgery (SEMLS) sequencing of intra-operative procedures (e.g. bone versus soft tissue procedures, and proximal versus distal procedures)