Friday, January 29, 2016

Strayer Procedure

In December last year, Joshua had a surgical procedure known as the "Strayer Procedure" or a Gastrocnemius release.  

There are two muscles that make up the calf, and they are called the soleus and the gastrocnemius.  The gastrocnemius is the larger of the two muscles, and they combine to form the achilles tendon at the back of the ankle.  Joshua's gastrocnemius muscle was too tight, causing what is known as a gastrocnemius equinus contracture.  For some time now we had been working on trying to remedy this with the use of an AFO (ankle-foot orthoses or leg brace) as well as stretching, exercises and serial casting and botox.   None of these strategies were effective in improving Joshua's equinus contracture, nor did they prevent it from getting worse.   Essentially, the tightness in Joshua's calf muscle was preventing him from having normal motion through his foot and causing him to walk and stand on his toes.  The unnatural walking pattern was very rough on his shoes, with him wearing out shoes within days to a few weeks if lucky.  It can also cause long term problems with the muscles and joints to continue walking with poor form.  For this reason, we made the decision to try the surgical option sooner than later, as the longer these problems are allowed to persist, the harder it can be to re-learn a better way of walking.    

Joshua's foot prior to his surgery- A Gastrocnemius Equinus Contracture caused him to walk and stand on his toes

The strayer procedure involves making an incision in the calf and locating the gastrocnemius tendon, which is essentially then cut.   The leg is then casted with the foot in a neutral position (at a right angle to the leg) which will cause the muscle to stretch.  As the tendon heals, it will heal in this new, elongated position, effectively lengthening the gastrocnemius muscle.   The procedure is done under General Anaesthesia and takes about an hour to complete.   Joshua was required to have an overnight stay in hospital following the procedure.  

The surgery itself went well, however Joshua is never a happy camper with general anaesthesia and always wakes up mad as hell, screaming the hospital down.  When he has had same day procedures, he usually screams until he is allowed to go home and co-operates with nothing and nobody.  In this instance however, since we were staying in overnight, we were taken to the children's ward from recovery, where Joshua proceeded to scream the ward down for a few hours.   He wanted nothing to do with his hospital bed, and the only place I was able to put him down was in his DoBuggy (his special needs stroller) so it was a good thing that I had it with us.   I think it felt familiar and safe to him, unlike a strange hospital bed.  

Resting in his DoBuggy Post Surgery

A bright spot during Joshua's hospital stay - Some laughs and smiles with one of the Starlight Foundation's "Starlight Captains"

He did sleep in the hospital bed that night though, with me squished into the bed with him.   (Fun times!).    The hospital stay seemed pretty unnecessary though, as other than Joshua's initial post anaesthesia rage, he was fine and didn't really need any special care.      He did not seem to be in any pain or require any pain relief, even though this would be expected following the surgery.  He was not allowed to weight bear at all for the first 2 weeks after the surgery, which was a nightmare.   He was trying to stand almost immediately after waking from anaesthesia and it was a really tough gig trying to stop him.   We got a walker on loan from his physio to try and give him some mobility without weigh bearing, and we used his stroller a lot to keep him contained but I am sure he walked on it way more than he should have!  

Being contained in his stroller at home to rest and recover while not allowed to walk

After 2 weeks he went back and was again placed under anaesthesia to have the cast changed and cast made to mould him for a new AFO.   With such a short time between visits,  Joshua apparently remembered what happens in theatre and was not happy about visiting again so soon!  

The Starlight Captains once again did their best to improve Joshua's mood with music and bubbles

Once that was complete, Joshua was officially in a weight bearing cast.  It didn't slow him down at all and he happily ran around on it without a care.

Cheeky Boy enjoying Christmas in his weight bearing cast

He had to remain in that cast for a further 4 weeks, bring him to a total of 6 weeks in a cast.   Being in a cast for 6 weeks is no easy thing, especially at this very hot time of year.  Joshua loves swimming, so it was very hard for him to not be allowed to swim and have his activities restricted to avoid getting his cast wet or sandy etc.  

I was relieved to go and get the cast removed, and was expecting Joshua to be his normal self considering he had spent the 6 weeks in the cast seemingly pain free and as active as ever.  To my surprise however, the moment he tried to take his weight on his castless leg, he collapsed to the ground and was unable to walk.   Sadly I did not bring his DoBuggy to that appointment so found myself having to carry him!  LOL.  He is on the smaller side for his age, but believe me - He is getting heavy!!  Immediately following the cast removal we had to go and have his new AFO fitted, and he was very teary and upset for the remainder of our time at the hospital that day, and it was evident that he was indeed in pain once the cast came off.        

The scar on Joshua's calf following his surgery

He went home that afternoon though, and was swimming in our pool as he usually would (but not taking any weight on his foot on the ladder of the pool).    He began to take a few tentative steps here and there but mostly he would hop around on one leg as his main mode of transport.

We are now at Day 10 since the cast was removed and he is now walking more than he is hopping.  He was initially unable to take any weight or steps on his leg when he was not wearing his AFO, but as of yesterday he began to take a few steps on bare feet and now today on Day 10, he has taken a number of steps with bare feet.  

The great news is that his foot is wonderfully flat, with his heel touching the floor.   No more toe walking.   He still needs to get his confidence up with his walking, but our job from here on out is to strengthen his leg muscles.  They have been weakened during the surgery so he now needs to build up his strength and try and achieve the best possible function from that leg.   We will be starting tomorrow by taking him to the pool where he can walk in the water and exercise his leg with the water assisting him with weight bearing.   (Our pool at home is too deep for this, so we need to take him somewhere else).    We also have some other play based suggestions from the physio to help exercise that muscle and make it strong again.
At this stage he has to wear his AFO for 8-10 hours a day.   He will be reviewed again by the surgeon in early March and we have another appointment with the orthotist about a week after that to change his current AFO, which is fixed, to a hinged AFO.

So overall, things have gone well with the surgery and things are looking positive, but we still need to  continue with the recovery and physio to get the best results.  


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