Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?

Abstract

BackgroundMedial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL).MethodsThis is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others’ findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval.ResultsThe first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed.ConclusionsTo the authors’ knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

Clinical Comparison of Percutaneous and Open Hamstring Lengthening in Children with Spastic Cerebral Palsy

“…In this study, we did not evaluate the postoperative recurvatum deformity in patients but all of them had isolated hamstring contracture and no one had gastrocnemius spasticity. In a recent study by Mansour et al 11 , although unacceptable damage to the muscular portion of both medial hamstrings with percutaneous lengthening occurred, they did not encounter any correlation between the PA gain and development of recurvatum deformity This study has some limitations like other retrospective studies with this group of patients. The patient population is small, postoperative followup is lacking and the patients were not evaluated according to the necessity of biceps tenotomy.…”

“…In a recent prospective anatomical study showing the effectiveness and safety of PHL, undesirable extensive muscle injury was reported with this percutaneous technique 11 . Although any accidental injury to the surrounding structures and neurovascular complications with PHL surgery was reported, they did not recommend PHL instead of OHL because of the unexpected muscle injury and less gain in PA with PHL.…”

“…Aside its advantages, there is an increased risk of injuring the popliteal vessels or sciatic nerve. Although a precise and clear description of OHL can be found in the literature, it is difficult to say the same thing for PHL 11 . The two types of PHL procedures reported in the literature are distal complete tenotomy of both tendons and myofascial lengthening at the muscle-tendon junction 12,13 .…”

The short-term effects of selective dorsal rhizotomy on gait compared to matched cerebral palsy control groups

“…We have demonstrated that those who had additional orthopaedic surgery were more flexed during gait before surgery and therefore had more improvements post-operatively. However, long-term results may be influenced by the type of orthopaedic surgery performed in the different surgical centres and one centre routinely carries out percutaneous hamstring lengthening’s potentially leading to increased injury to the muscle versus open lengthening [22].…”

Improving gait and lower-limb muscle strength in children with cerebral palsy following Selective Percutaneous Myofascial Lengthening and functional physiotherapy

“…Some authors have noted that without active physiotherapy and orthopaedic interventions children with CP can worsen physically, falling in a lower Gross Motor Function Classification System (GMFCS) level (Novak, 2014). (Mansour et al, 2017;Mitsiokapa et al, 2010).…”