Guide to

Varus Rotational Osteotomy (VRO)

Hamstring Lengthening

Tendo Achilles Lengthening (TAL)

Gastrocnemius Recession

Pediatric Education Committee Contributors

Lisa Ipp, MD

H. Susan Cha, MD

Stephanie Perlman, MD

Leon Root, MD

David Scher, MD

Lucia Fabrizio, MSN, RN, CPNP

Anna Givant, RN

Cindy MacDonald, RN

Lorraine Montuori, LCSW

Jennifer Crane, PT/DPT

Michelle Patterson, OTR/L

Maureen Suhr, PT/DPT

Members of the Patient Education Council

©2009 Hospital for Special Surgery

This booklet is designed to provide patients with information about VRO, hamstring lengthening and TAL or gastrocnemius recession and to help parents care for their child at home. During the hospital stay, much of the care will be demonstrated and reviewed in preparation for going home. This guide is intended to supplement the information that the doctors and nurses provide.

Please take the time to read through this booklet so that any questions you may have can be answered before you leave the hospital. Upon discharge, we will provide information on where to call with questions that may arise during the recovery process.

CONTENTS

Varus Rotational Osteotomy 4

Hamstring Lengthening 6

Tendo Achilles Lengthening / Gastrocnemius Recession 8

Physical Therapy 11

Stretches 12

Active Exercises 13

Notes On Exercises 14

Emergency Checklist 15

VARUS ROTATIONAL OSTEOTOMY (VRO)

Your child is about to have hip surgery in order to correct hip dysplasia (abnormally formed hip bones). The upper end of the thigh bone (femur) is cut and rotated to fit more directly into the hip socket (acetabulum).

The osteotomy procedure is often done to angle the upper femur (the ball of the hip joint) into the hip socket. Usually the hip bone is abnormally twisted (called femoral anteversion), and this twist is also corrected at the time of the surgery. After the bone is cut and its position is corrected, the pieces are put back together and held in place with a plate and screws.

What happens before the surgery?

You and your child will come for pre-admission testing approximately two weeks before the scheduled surgery. At that time, you will have a pre-operative appointment with your surgeon to ask any additional questions regarding your child’s surgery. You will also meet the pediatrician who will take a detailed history and perform a physical exam on your child. This pediatrician will also care for your child while he or she is in the hospital. Finally, the nursing staff will provide a tour of the inpatient unit where your child will be staying after surgery.

What happens after the surgery?

After the surgery, your child’s surgeon may decide to place your son or daughter in a cast. This cast is usually applied in the operating room while your child is still asleep. The cast that extends from the belly button to the top of the toes is called a “Hip Spica Cast”. Typically, the cast remains on your child from three to six weeks after surgery. Your child will have restricted weight bearing during this time period to allow for proper healing. Very specific instructions on how to care for your child in the spica cast will be provided by the surgeon and reinforced by the physical therapists and nursing team.

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Will my child have discomfort or pain?

Your child may have some discomfort or pain following surgery; however, this can be controlled with pain relievers and muscle relaxants. A pre-scription will be provided before you leave the hospital.

Always follow the instructions related to the dosing and schedule of the medication. The nurses and doctors will teach you how to monitor for early signs of pain in your child. Medication should be administered when these early signs become apparent, rather than waiting, because it can take some time for the medications to take effect. Remember, it is also important to administer pain medication thirty (30) minutes prior to any physical therapy treatments.

How long will we be in the hospital?

The usual hospital stay is four to six days.

When will we be seen by our surgeon again?

Prior to going home, the nursing staff will give you very specific instructions on how to care for your child at home. You should check with your surgeon’s office or clinic to see when you should return for follow-up, and be sure to schedule this appointment with the office or clinic staff.

Your child’s surgeon will usually have you return to the office approximately 2 weeks after surgery to check that the incisions are healing properly. Most of the time our surgeons use dissolvable sutures that do not need to be removed.

What if my child has problems after discharge and before we are scheduled to return?

You should always feel free to contact the surgeon’s office if any problems or concerns arise after discharge; there is always a pediatric orthopedic surgeon on-call for emergencies. For non-emergencies, please contact the surgeon’s office during regular business hours.

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HAMSTRING LENGTHENING

Sometimes a hamstring lengthening procedure will be indicated in addi-tion to the VRO procedure. Hamstring lengthening is performed to im-prove your child’s ability to straighten his or her knees while walking. The hamstrings are the muscles in the back of the thigh that bend the knees. In children with cerebral palsy and some other conditions, the hamstrings can become shortened or tight as the child grows.

What happens in the operating room?

Before and during the procedure, the anesthesiologist will administer medication which will keep your child in a deep sleep and completely unaware of the procedure. The surgeon will make an incision (cut) that is usually about two inches long on the back of the leg, either behind the knee or below the buttocks, and cut the part of the muscle called the tendon, allowing it to stretch out in a lengthened position. There are some variations of this procedure which you should discuss with your surgeon.

When will I be able to see my child?

The actual hamstring lengthening takes approximately one hour, but often other procedures are done at the same time. Please keep in mind that this is just an estimate, and there are many factors that can cause delays in start time, in which case the surgery may seem to take much longer.

Once the procedure is finished, your child will be brought to the post-anesthesia care unit (PACU) and you will be allowed and encouraged to visit. Waking up from anesthesia can be confusing to a child, but the PACU nurses will be there to reassure and support both you and your child. Your child may be in the PACU for several hours.

What will my child’s leg look like?

There will likely be dressings on the incisions, as well as knee splints (immobilizers) on each leg or a cast. Knee immobilizers are removable foam splints that wrap around the leg and are secured with Velcro straps. These removable splints are designed to keep the leg straight or extended so that the hamstrings heal in the lengthened position.

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How long will we be in the hospital?

If this hamstring lengthening is the only surgery and there are no other health issues, your child may stay in the hospital for one night. Hamstring lengthening is sometimes combined with other surgical procedures and, if so, then it may require the use of casts after surgery and a longer hospital stay. How long does my child need to wear knee immobilizers?

Your child will remain in the knee immobilizers most of the time (includ-ing while in bed) during the first several weeks after surgery. They may be removed for exercises and bathing. The surgeon will advise when the schedule may be changed to wear only at nighttime, and when they even-tually may be discontinued.

How do we manage driving home from the hospital and re-turning for our follow-up appointment in our car?

Always secure your child in the car with a seat belt. When your child is in the car, you may remove the immobilizers and allow the knees to bend. These periods of time without the immobilizers will not cause any prob-lems. The immobilizers should be placed on as soon you arrive at your destination.

When will we be seen by our surgeon again?

The first post-operative visit may be scheduled any time from ten days to two weeks following surgery. This depends on your child’s individual needs and whether your child was placed in casts or knee immobilizers after surgery.

TENDO ACHILLES LENGTHENINGGASTROCNEMIUS RECESSION

Sometimes a Tendo Achilles Lengthening (TAL) or gastrocnemius recession procedure is also performed with hamstring lengthening. Your child might need this procedure for a tight Achilles tendon that prevents walking with the foot flat, and causes walking on tip-toes. This tightness results from the inability of the muscle or tendon to adapt to the child’s growth.

What does the surgery involve?

The Achilles tendon is located behind the ankle and is attached to the gastrocnemius and soleus muscles, both located in the calf.

There are many ways to lengthen these muscles and tendons. The technique your child will have depends on many factors: the severity of the tightness, the underlying conditions causing the tightness, and the age of the patient, among other factors. Sometimes a small incision is made on the side or behind the calf to release the casing around the muscle or the tendon. Other times, small incisions may be used behind the ankle to lengthen the tendon. You should discuss the details of the surgical technique with your surgeon.

What will my child’s leg look like after surgery?

Below-the-knee casts are placed on your child’s leg in the operating room immediately after the surgery. Sometimes patients may be given a rubber-soled shoe so that they can walk in the casts.

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Will my child be able to ride in the car?

There should be no difficulty with positioning the child for car rides.

When will we be seen by our surgeon again?

Typically, your child will return in three to four weeks for the casts to be removed. A brace may be prescribed by your surgeon at that time.

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PHYSICAL THERAPY FOLLOWING VARUS ROTATIONAL

OSTEOTOMY (VRO) AND TENDON PROCEDURES

While in the hospital, your child may receive physical therapy. At first your child’s legs may feel stiff and sore after surgery. Throughout recovery, exercise plays a crucial role in keeping your child’s muscles flexible and in maintaining muscle strength. Physical therapy is hard work and will take time. Sometimes it will hurt, but it is important to do these exercises. Soon your child will be returning to regular activities.

After some surgeries, the doctor may want your child to practice walking or use a wheelchair. He or she may not want your child to put all of his or her weight on the operated leg. A physical therapist will teach your child how to use crutches or a walker and how to walk and climb stairs safely. If your child usually uses a wheelchair for mobility, the physical therapist will review how to safely get into and out of the wheelchair with help.

On the following page is a list of commonly taught exercises to help your child recover after surgery. These exercises should be performed slowly and gently. A physical therapist will teach your child exactly which exercises are important to do at home based on his or her surgery. You (or a caregiver) will help your child do these exercises at home.

Always check with your child’s doctor and/or physical therapist before beginning an exercise program. If you have any questions, please contact the Pediatric Rehabilitation Department at 212.606.1368.

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Stretches

Hold your child’s heel with one hand. Support the sole of the foot on your forearm. Use the other hand to hold the knee straight. Pull the heel as you push your forearm against the sole of the foot. When you feel resistance, hold for 30 seconds. Repeat 4 times, three times per day.

Lift your child’s leg, keeping the knee straight. When you feel resistance, hold for 30 seconds. Repeat 4 times, three times per day.

Bring your child’s leg out to the side while keeping the opposite leg still and both knees straight. When you feel resistance, hold for 30 seconds. Repeat 4 times, three times per day.

Heelcord StretcH

HamString StretcH

adductor StretcH

While your child lies on his/her side, bend the top knee slightly and bring the leg backwards. Place one hand on your child’s hip to prevent arching of the back. When you feel resistance, hold for 30 seconds. Repeat 4 times, three times per day.

Hip Flexor StretcH

Active Exercises

The doctor may want your child to perform some gentle exercises to keep his or her hips and knees strong. Here are some exercises that a physical therapist may teach your child to do after surgery. It’s alright for someone to help move your child’s legs until he or she is able to do it on their own.

Hip abduction Keep knees straight. Move the leg out to the side. Repeat 10 times, three times per day.

ankle pumpS Move the foot at the ankle up and down. Repeat 10 times, three times per day.

Heel SlideS While lying on the back, gently and slowly bend the hip and knee as shown in the picture. Hold for 5 seconds. Repeat 10 times, three times per day.

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NOTES ON EXERCISES

Please write notes and/or questions here. If you are describing a complete exercise given to you verbally or by demonstration, we suggest you enter at least four things about it:

1. An easy-to-remember name.2. How to do it.3. How frequently to repeat it.4. Any precautions; for example, regarding pain or range of motion.

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Please do not hesitate to contact your physical therapist with any questions or concerns at 212.606.1368.

We hope this information has been helpful. The health care team is here to answer your questions, and we encourage you to speak with us about any questions or concerns you may have.

EMERGENCY CHECKLIST

call Your doctor or nurSe immediatelY iF YOUR

CHILD IS EXPERIENCING ANY OF THE FOLLOWING:

• The incision site appears red and warm• The incision site has drainage • Your child is running a fever of 100.4 degrees or higher• Your child is becoming increasingly irritable or inconsolable • Your child is not getting relief from the pain medication

IMPORTANT PHONE NUMBERS

Child’s Name

HSS Doctor’s Name

Number

Pediatrician’s Name

Number

Pediatric Nurse Practitioner

Emergency Contacts

Name

Number

Name

Number15

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Hospital for Special Surgery is an affiliate of NewYork-Presbyterian Healthcare System and Weill Cornell Medical College.

535 East 70th StreetNew York, NY 10021tel 212.606.1000www.hss.edu