Q: My five-year-old daughter walks on the forefoot of her right leg since birth. Her right foot remains bent towards the forefoot from the ankle and there is mild spasticity at this spot. She is able to walk independently, but she cannot walk fast and loses balance. Her left leg is normal. She was kept in ICU immediately after birth because stool had gone into her mouth during delivery and breathing was paused. The attending doctor said she had jaundice. As per the orthopaedic doctors, her muscles are stiff and minor surgery to loosen the muscle should be done. We consulted a child neurologist who said that surgery can be done between the age of 7 to 12 years. We are giving her botox injections as advised by the doctor, but so far there is no improvement. He also said that there is mild damage to her left brain during delivery. We want to go for surgery. What is the right age for surgery in her case?

A:Your child seems to be a patient of right sided spastic hemiplegic cerebral palsy. The right side of the body is affected with the lower limb more so. As a paediatrics ortho surgeon, my endeavour in your childs case would be to try to normalize her gait (walking style) as much as possible. Initially, regular physiotherapy (PT) and occupational therapy (OT) play a very important role along with casting/orthosis (to stretch out the tendo-achilles, usually) where required. I would reserve oral medications and botox injections to a select group, more so to temparorily reduce tightness in muscle groups to get the child into the non-operative treatment program; or to delay surgery till an appropriate time. I would resort to surgery when multiple muscle groups in the lower limb are so tight that they are non-responsive to PT; and the age for surgery is usually between 5 to 8 years. It is important to remember that surgery is only a tool in the overall management which is multidisciplinary, consisting of pediatric orthopaedic surgeon, paediatric neurologist, physiotherapist, occupationaltherapist and orthotist (Who tailors Braces/AFOs).