Comparison of the Results of Primary Versus Repeat Hamstring Surgical Lengthening in Cerebral Palsy

Abstract

Background: Hamstring surgical lengthening (HSL) has been frequently performed for the correction of knee flexion deformity in cerebral palsy (CP), although recurrence is described in long-term follow-up. Repeat hamstring surgical lengthening (RHSL) can be an option for recurrent knee flexion deformity; however, the results of this approach are still controversial. The purpose of this study was to compare the results of primary HSL and RHSL in CP. Methods: Patients with spastic diplegic CP, Gross Motor Function Classification System levels I to III, underwent bilateral medial HSL with complete documentation in the gait laboratory before and after the intervention, were included in the study. A total of 229 subjects met the inclusion criteria and were divided into 2 groups: group A was formed by those who received medial HSL for the first time (185 patients), and group B was composed of individuals who underwent RHSL (44 patients). Clinical and kinematic parameters were evaluated before and after the intervention, and the results compared. Results: The groups were matched with regard to sex distribution, Gross Motor Function Classification System levels, and follow-up time (>2 y). Popliteal angle was reduced in groups A (60.3 to 51.4 degrees, P<0.001) and B (56.1 to 51.5 degrees, P=0.001) after the intervention. Knee flexion at initial contact was reduced from 40.8 to 28.9 degrees in group A (P<0.001) and from 40.4 to 35.1 degrees in group B (P=0.001). Reduction of minimum knee flexion in the stance phase (24.9 to 17.5 degrees, P<0.001) and improvement of the Gait Deviation Index (52.9 to 60.2, P<0.001) occurred only in group A. Anterior pelvic tilt (APT) increased in groups A (from 17 to 19.5 degrees, P<0.001) and B (from 14.9 to 19.4 degrees, P<0.001) after treatment. Finally, in the comparison between groups, the reduction of knee flexion at initial contact was more significant in group A (P<0.001), whereas the increase of APT was higher in group B. Conclusions: In the present study, the improvement of knee extension during the stance phase was observed only after the primary medial HSL. Moreover, the increase of APT was more significant when RHSL was performed. Level of Evidence: Level III.

Long-term outcome of hamstring lengthening versus transfer and the role of biceps femoris lengthening in patients with spastic diplegia and dynamic knee flexion in gait

“…In terms of the first issue, the overall efficacy of hamstring surgery, this study of 49 original subjects, showed improvement in passive and dynamic measures at the sagittal plane knee at 1 year post-op, and most importantly, improvement in dynamic knee extension in stance, which was maintained in 60%–70% of patients over a long-term follow-up period (7–15 years), although there was return to baseline of many of the passive measures. The findings are consistent with the study published by Õunpuu et al 18 and Morais Filho et al 20 who reported slight decrease in dynamic knee extension at the long-term follow-up compared to values measured at 1 year post-op, but they felt this could be due to natural progression of gait in children with CP which has been shown to decline over time.…”

Finding consensus for hamstring surgery in ambulatory children with cerebral palsy using the Delphi method

“…Problems reported in the literature after HSL include incomplete correction, recurrent crouch, over-correction and recurvatum, increased APT, and less favorable results following revision or repeat HSL. 27 – 31 Excessive APT has long been identified as a potential problem following HSL, 27 , 30 , 31 with recent authors indicating that APT seems to be an issue in children functioning at GMFCS level III, but not in those functioning at GMFCS levels I–II 31 and appears to be a greater risk following medial and lateral HSL, 27 after revision HSL, 28 and possibly in females. 32 Genu recurvatum may be more common with combined medial and lateral HSL, but can occur after isolated medial lengthening 33 and may be related to plantar flexion–knee extension coupling, due to either residual calf tightness or spasticity.…”

“…Such conclusions are supported by previously published literature. 28 , 29 Many panel members noted that repeat HSL (following previous HSL) often is not helpful, thus leading to the increased use of other soft tissue and bony procedures more recently, including anterior distal femoral hemiepiphysiodesis, distal femoral extension osteotomy, patella tendon shortening or advancement, or a combination thereof, for those with recurrent crouch. Alternatives to repeat HSL include guided growth in the skeletally immature patient, distal femoral extension osteotomy (DFEO) with patellar tendon shortening or advancement, and combinations of these procedures.…”

The Effects of Preterm Birth on Musculoskeletal Health-Related Disorders

“…In cases with dystonia, intrathecal baclofen application was shown to be beneficial [ 52 ]. Depending on the underlying problem, surgical procedures normally consist of derotational osteotomies [ 53 , 54 ], open reduction of hip dislocations with or without concomitant bony procedures [ 55 , 56 , 57 ], tenotomies [ 58 , 59 , 60 , 61 , 62 ] or guided growth with temporal (hemi) epiphysiodesis [ 63 , 64 , 65 , 66 ]. Care has to be taken with tenotomies for gaining more range of motion (ROM) of the affected joints which is generally accompanied by a further weakening of the muscle in our clinical experience.…”