Cerebral palsy is classified into four main types based on movement patterns: Spastic CP (70-80% of cases) characterized by increased muscle tone and stiffness—further divided into spastic hemiplegia (one side affected), spastic diplegia (primarily legs affected, most common in premature babies), and spastic quadriplegia (all four limbs affected). Dyskinetic CP (10-15%) involves involuntary, uncontrolled movements including athetosis and dystonia. Ataxic CP (5-10%) causes problems with balance and coordination. Mixed CP shows features of multiple types. Surgical planning differs significantly: Spastic CP responds best to soft tissue releases and tendon lengthening to address fixed contractures; these children are the best surgical candidates. Dyskinetic CP has less predictable surgical outcomes because the primary problem is abnormal movement control rather than fixed deformity—surgery is selective, focusing on specific functional goals. Ataxic CP rarely requires orthopaedic surgery. The distribution pattern (hemiplegia, diplegia, quadriplegia) determines which limbs require intervention and the complexity of surgery. GMFCS level (I-V) is critical: ambulatory children (GMFCS I-III) have different surgical goals (improve gait efficiency, independence) compared to non-ambulatory children (GMFCS IV-V) where goals focus on positioning, care facilitation, and pain prevention.

Age considerations for CP surgery are complex and depend on the procedure type and goals. Soft tissue procedures (muscle/tendon lengthening, releases) can be performed as early as 3-4 years when contractures interfere with function, gait, or positioning. However, there is a risk of recurrence with growth, potentially requiring repeat procedures. Single-Event Multilevel Surgery (SEMLS) for ambulatory children is optimally performed between ages 6-10 years, when gait pattern is mature enough to assess comprehensively but before fixed bony deformities develop and while rehabilitation potential is high. Bony procedures (osteotomies) are typically performed after age 6-8 when skeletal maturity is sufficient, though specific procedures like femoral osteotomy for hip subluxation may be done earlier (4-6 years) to prevent hip dislocation. Hip surveillance and early intervention for hip dysplasia should begin by age 2-3 to prevent painful dislocation. Upper limb surgery is often delayed until age 6-8 or later when the child can participate in goal-setting and intensive hand therapy. Spinal surgery for scoliosis is typically performed in adolescence when growth is nearly complete, though severe progressive curves may require earlier intervention. In Bihar's context, many children present late, and surgery may need to be performed at older ages to address established deformities. The guiding principle is: operate when contractures or deformities interfere with current function or threaten future function, and when the child can participate meaningfully in rehabilitation.

Single-Event Multilevel Surgery (SEMLS) involves performing multiple soft tissue and/or bony procedures at different anatomical levels during a single operation under one anesthetic. For example, a child with spastic diplegia might undergo hamstring lengthening, hip adductor release, psoas lengthening, and gastrocnemius recession all in one surgery. The alternative is staged procedures—addressing one or two levels at a time over multiple separate operations. SEMLS advantages include: one hospitalization and anesthetic exposure rather than multiple, simultaneous correction of all deformities allows balanced rehabilitation, more cost-effective overall, less disruption to school and family life, potentially better functional outcomes because all components of the gait pattern are addressed together. Disadvantages include: longer single operation (4-6 hours), more intensive immediate postoperative care, more complex rehabilitation initially, higher initial cost. Research evidence generally favors SEMLS for ambulatory children (GMFCS II-III) with multiple level involvement—studies show comparable or better functional outcomes with fewer total surgeries compared to staged approaches. However, SEMLS requires: comprehensive preoperative gait analysis, experienced surgical team, strong rehabilitation infrastructure, and committed family support. Not all children are SEMLS candidates—very young children, those with severe medical comorbidities, or those with limited single-level problems may be better served by staged procedures. At Arthoscenter, we use comprehensive gait analysis and multidisciplinary assessment to determine the optimal surgical strategy for each child, whether that is SEMLS or staged approach.

Setting realistic expectations is crucial for family satisfaction. Cerebral palsy surgery CANNOT cure CP, normalize movement completely, or eliminate the need for ongoing therapy. What it CAN do: reduce spasticity-related contractures, improve joint alignment and range of motion, enhance gait efficiency and reduce energy cost of walking, facilitate transfers and positioning, reduce pain from joint deformities, make hygiene and dressing easier for caregivers, delay or prevent secondary complications like hip dislocation or severe scoliosis, and improve quality of life. Specific outcomes depend on GMFCS level: For GMFCS I-II (community ambulators), goals include improving gait aesthetics, reducing compensatory movements, increasing walking speed and endurance, and reducing long-term joint stress. Success rates for improved gait kinematics: 70-80%. For GMFCS III (household/limited community ambulators with aids), goals include maintaining or improving walking ability with assistive devices, easier transfers, better standing tolerance. Success in maintaining ambulatory status: 60-75%. For GMFCS IV-V (non-ambulatory), goals focus on improving sitting balance and posture, preventing painful hip dislocation, facilitating positioning and caregiving, reducing pain from contractures. Success in achieving these goals: 75-85%. Overall, studies show 60-80% of children achieve their primary functional goals after CP surgery, but success heavily depends on: appropriate patient selection, comprehensive surgical planning, intensive postoperative physiotherapy (THE most critical factor), family commitment, and realistic goal-setting aligned with GMFCS level. Functional improvements may be modest but meaningful—walking independently for household distances instead of requiring assistance, sitting comfortably for classroom activities instead of requiring special positioning equipment, or reducing caregiver burden for hygiene and dressing.

These are complementary approaches targeting different aspects of CP. Selective Dorsal Rhizotomy (SDR) is a neurosurgical procedure that permanently reduces spasticity by cutting selected sensory nerve rootlets in the spinal cord. It addresses the neurological cause of spasticity but does not correct established contractures or bony deformities. SDR is best for: young children (typically 3-8 years) with pure spastic diplegia, good strength, minimal fixed contractures, and good selective motor control. Benefits include permanent spasticity reduction, improved ease of movement, and reduced energy expenditure. Limitations: does not correct fixed deformities, requires intensive post-SDR physiotherapy, and has risks including sensory changes, bladder/bowel dysfunction, and spinal deformity. Orthopaedic surgery addresses the musculoskeletal consequences of CP—contractures, deformities, and mechanical malalignment. It can be performed at any age and is suitable for all CP types. Benefits include correction of fixed deformities, improved joint alignment, and addressing specific functional limitations. Limitations: does not reduce spasticity at its source, and contractures may recur if spasticity persists. Many children benefit from BOTH approaches sequentially: SDR first (at age 4-6) to reduce spasticity and facilitate therapy, followed by orthopaedic surgery later (age 8-10) to address any residual contractures or deformities that develop despite therapy. This combined approach can produce excellent outcomes in carefully selected patients. However, SDR availability is limited in India including Bihar—few centers offer it, and cost is high (₹6-10 lakhs). At Arthoscenter, we work with neurosurgical colleagues when SDR is appropriate, but most of our CP patients are managed primarily with orthopaedic interventions, therapy, and sometimes botulinum toxin injections for spasticity management.

Hip surveillance refers to systematic monitoring of hip development in children with CP through regular clinical examination and X-rays. It is critically important because hip displacement (subluxation/dislocation) is one of the most common and serious complications of CP, occurring in 30-40% of children overall and up to 60-90% of non-ambulatory children (GMFCS IV-V). Hip displacement develops gradually due to muscle imbalance—spastic hip adductors and flexors pull the femoral head out of the acetabulum, especially when combined with poor weight-bearing and abnormal positioning. The process is often painless initially, so without surveillance it goes undetected until severe dislocation occurs. Consequences of untreated hip dislocation include: severe pain from arthritis, difficulty with positioning and sitting, pressure sores, impaired perineal hygiene, pelvic obliquity contributing to scoliosis, and significantly reduced quality of life. Hip surveillance protocols recommend: clinical hip examination and anteroposterior pelvis X-ray at age 2-3 years for all children with CP (except GMFCS I who walk independently), then repeated every 6-12 months depending on GMFCS level and hip migration percentage. X-rays are measured for Migration Percentage (MP)—the percentage of femoral head not covered by acetabulum. Normal MP is <10%; MP >30% indicates progressive displacement requiring intervention; MP >40% usually requires surgery. Early intervention when hip displacement is detected (MP 30-40%) may involve soft tissue procedures alone (adductor and psoas release). More advanced displacement (MP 40-70%) requires femoral osteotomy ± pelvic osteotomy. Established dislocation (MP >90%) may require complex reconstructive surgery or in severe cases, salvage procedures for pain management. The key principle: hip surveillance allows early detection and preventive intervention before painful dislocation occurs. Unfortunately, systematic hip surveillance is not yet widely implemented in Bihar, and many children present with established painful dislocations requiring complex surgery. At Arthoscenter, we advocate strongly for hip surveillance and work to implement it through our CP clinics.

Physiotherapy is absolutely THE MOST CRITICAL factor determining surgical success—more important than surgical technique itself. Surgery creates the mechanical opportunity for improved function by lengthening tight muscles, correcting deformities, and rebalancing forces. But realizing that potential requires intensive, expert physiotherapy to: maintain the range of motion gained surgically, strengthen muscles that may be weakened by lengthening procedures, retrain gait patterns to take advantage of improved alignment, prevent compensatory abnormal movement patterns from developing, and gradually progress to functional activities. The intensity required is much higher than many families expect: First 3 months post-surgery: 5-6 sessions per week of structured physiotherapy plus daily home exercises. Months 3-6: 4-5 sessions weekly with continued home program. Months 6-12: 3-4 sessions weekly. Beyond 1 year: 2-3 sessions weekly plus lifelong daily stretching and exercise routine. Each session is typically 45-60 minutes. Without this intensity, contractures recur, surgical corrections are lost, and functional goals are not achieved. Studies show that inadequate post-surgical physiotherapy is the number one cause of poor outcomes after otherwise technically successful CP surgery. The challenges in Bihar's context: Limited number of physiotherapists trained specifically in pediatric neurological rehabilitation. In rural areas, accessing regular physiotherapy is extremely difficult. Cost of intensive therapy over many months can be prohibitive for many families—private physiotherapy in Patna typically costs ₹500-800 per session, meaning 5-6 sessions weekly for 3 months = ₹30,000-60,000 just for therapy. At Arthoscenter, we address this through: in-house physiotherapy department with pediatric neurological specialists, family training programs where parents learn to continue therapy at home, subsidized therapy costs for economically disadvantaged families, and connecting families with government rehabilitation facilities. We emphasize to families before surgery: the commitment to intensive physiotherapy is as important as the decision for surgery itself. Without that commitment, surgery should be delayed or reconsidered.

While CP surgery is most commonly performed in childhood, adults with CP can definitely benefit from orthopaedic procedures, though goals and outcomes may differ. Adult CP surgery addresses: progressive painful contractures that develop despite previous surgery or therapy, hip pain from subluxation or dislocation that was undetected or untreated in childhood, painful foot deformities interfering with footwear or ambulation, upper limb contractures affecting hygiene or self-care, and spinal deformity causing pain or sitting imbalance. The differences in adult CP surgery include: goals are often more focused on pain relief, maintaining current function, and facilitating care rather than improving function, bony deformities are more established and may require more extensive surgery, rehabilitation potential may be less than in children due to longstanding adaptive patterns and muscle changes, but adults can be more motivated and compliant with therapy, surgery may be combined with pain management strategies like neurolysis or botulinum toxin, and realistic expectation-setting is even more critical. Common adult CP procedures include: hip reconstruction or salvage procedures (arthroplasty, proximal femoral resection) for painful dislocated hip, tendon releases for contractures affecting hygiene, foot fusion procedures for severe rigid deformities, and spinal fusion for painful progressive scoliosis. Outcomes can be very satisfying when goals are appropriate—many adults achieve significant pain reduction, easier caregiving, better positioning, and improved quality of life. At Arthoscenter, Dr. Gurudeo Kumar has extensive experience with adult CP surgery and takes a comprehensive approach including pain management, realistic goal-setting, and planning for long-term maintenance. One challenge in Bihar is that many adults with CP never received any surgical intervention in childhood despite clear indications, presenting with severe neglected deformities that are more complex to treat. Even in these cases, surgery can often provide meaningful improvements in pain, positioning, and quality of life, though expectations must be carefully managed.

As with any major orthopaedic surgery, CP surgery carries risks that must be weighed against potential benefits. General risks include: infection (2-5% depending on extent of surgery and nutritional status), wound healing problems (higher risk in malnourished children or those with skin sensitivity), anesthesia complications (careful preoperative assessment needed for children with seizures, respiratory issues, or swallowing problems), blood loss requiring transfusion (more common with multilevel or pelvic surgery), pressure sores during prolonged immobilization (prevention crucial in children with sensory impairment), and venous thromboembolism (rare in children but possible with prolonged immobilization). Specific orthopaedic complications include: Over-lengthening weakness—excessive muscle lengthening can create new weakness and actually worsen function; requires careful surgical judgment. Under-correction—insufficient release leaves residual contracture requiring revision. Recurrence of deformity—occurs in 20-30% of cases over years, especially with continued growth and persistent spasticity; emphasizes importance of ongoing therapy and spasticity management. Neurovascular injury—rare but can occur with procedures near nerves and vessels. Loss of correction—casts or fixation may slip, allowing deformity to recur during healing. Fracture—can occur through weakened or osteoporotic bone during surgery or postoperatively. Specific to certain procedures: Hip surgery may result in avascular necrosis of femoral head (rare), nerve injury (sciatic nerve during hip surgery ~1%), or recurrent dislocation if soft tissue balance not achieved. Foot surgery may result in stiffness, overcorrection creating new deformities, or wound complications. Spinal surgery carries higher risks including neurological injury, implant complications, and pseudarthrosis. To minimize complications, Dr. Gurudeo Kumar employs: meticulous preoperative assessment and optimization, careful surgical technique with intraoperative monitoring, appropriate postoperative protocols including pressure sore prevention, experienced anesthesia team familiar with CP patients, and close postoperative monitoring. Families should understand: some degree of surgical complications is unavoidable in complex multilevel surgery, but serious permanent complications are rare (<2%) in experienced hands. The benefits of appropriately indicated surgery typically far outweigh risks.

CP surgery costs vary widely based on extent and complexity. At Arthoscenter in Patna: Single-level soft tissue procedure (e.g., hamstring lengthening): ₹75,000-1,25,000 including surgeon fees, hospital stay (3-5 days), anesthesia, and medications. Multi-level soft tissue procedures (SEMLS without bony surgery): ₹1,50,000-2,50,000. Complex procedures including osteotomies: ₹2,50,000-4,00,000. Hip reconstruction surgery: ₹2,00,000-3,50,000. These costs cover surgery only—additional expenses include: preoperative assessments and imaging (₹10,000-20,000), postoperative physiotherapy (₹30,000-60,000 for first 3 months if done 5-6x weekly), orthoses/braces (₹15,000-50,000 depending on type), follow-up visits and any adjustments or minor procedures. Total first-year cost for comprehensive CP surgery and rehabilitation can range ₹2,00,000-6,00,000 depending on complexity. This is financially challenging for most Bihar families. Available financial support: Government health insurance schemes—Ayushman Bharat PMJAY covers up to ₹5 lakhs annually for empaneled hospitals; check if your hospital is empaneled and CP surgery is covered. State government disability schemes—Bihar State Disability Pension and various disability welfare programs may provide limited financial assistance. NGO support—organizations like Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS/Jaipur Foot), Rotary clubs, and local charitable organizations sometimes support CP surgeries. Crowdfunding platforms—Ketto, Milaap, and others have been successfully used by Bihar families to raise funds for CP surgery. Corporate CSR programs—some companies support medical treatment for underprivileged children under CSR mandates. At Arthoscenter, we work with families to: navigate insurance and government schemes, provide cost-effective treatment without compromising quality, arrange subsidized or free physiotherapy for economically disadvantaged patients through our charitable programs, and connect families with NGOs and support organizations. Dr. Gurudeo Kumar believes every child deserves the opportunity for improved function regardless of economic status, and we make every effort to make surgery accessible. Families should discuss financial concerns openly during consultation—solutions can often be found.