Preoperative Patient Care A 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 B 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 C 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 Operative Techniques 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 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 G 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 H 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. I 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 J 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 K 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 Postoperative Patient Care O 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 R 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.