The increase of anterior pelvic tilt after semitendinosus transfer to distal femur in patients with spastic diplegic cerebral palsy

Filho, Mauro César de Morais; Fujino, Marcelo H.; Kawamura, Cátia Miyuki; Santos, Carlos Alberto dos; Lopes, José Augusto Fernandes; Blumetti, Francesco Camara; Mattar, Rames

doi:10.1097/bpb.0000000000000577

Cited by 8 publications

(6 citation statements)

References 20 publications

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“…More recently, however, there has been an increase in articles related to HST surgery. [43][44][45][46][47][48][49][50][51] From a theoretical basis, transfer of ST to the adductor tubercle may have the following advantages over HSL. It converts a two-joint muscle to a one-joint muscle, thereby simplifying its action.…”

Section: Hamstring Transfermentioning

confidence: 99%

“…46,47 Of the nine more recent studies in the literature reporting the outcomes of ST transfer, five studies compared HSL and HST and four reported HST only. [45][46][47][48][49][50][51] However, the studies were heterogeneous in terms of inclusion criteria, including GMFCS levels, as well as concomitant transfers and inclusion/exclusion of lateral HSL. The results were mixed, and some longitudinal studies from the same institution demonstrated that early differences between the HST and HSL groups dissipated over time.…”

Section: Hamstring Transfermentioning

confidence: 99%

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

Kay

McCarthy

Narayanan

et al. 2022

Journal of Children's Orthopaedics

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Purpose: There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. Methods: The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. Results: The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. Conclusion: The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. Level of evidence: level V.

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Section: Hamstring Transfermentioning

confidence: 99%

Section: Hamstring Transfermentioning

confidence: 99%

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

Kay

McCarthy

Narayanan

et al. 2022

Journal of Children's Orthopaedics

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“…Despite good short- and mid-term results after hamstring lengthening, deterioration in gait and recurrence of flexed knee gait have been reported [ 8 ]. A further side effect of hamstring lengthening is an increase in anterior pelvic tilt, which might mediate the recurrence of flexed knee gait [ 9 , 10 , 11 ]. Attempts to convert the muscle group into a monoarticular function also showed no improvement in pelvic inclination [ 8 , 12 ].…”

Section: Introductionmentioning

confidence: 99%

Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy

Geisbüsch

Klotz²,

Putz

et al. 2022

Children

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Background: Distal femoral extension and shortening osteotomy (DFESO) seems to be an effective method for the treatment of flexed knee gait in children with cerebral palsy. Nevertheless, studies investigating the mid- and long-term outcomes after such procedures are lacking in the literature. Therefore, the purpose of this study was to assess the mid-term outcomes regarding sagittal plane kinematics of the knee after DFESO with or without concomitant patella advancement. Furthermore, an evaluation of the postoperative course and possible recurrence of flexed knee gait was planned. Methods: In a prospective observational study, 19 patients (28 limbs; mean age 11.8 years (6.7–16.0 years)) were examined using 3-D gait analysis and clinical exam before (E0) and at a mean of 38 months (E2: 24–55 months) after surgery. Fifteen patients (22 limbs) had an additional first postoperative gait analysis (E1) after a mean of 14 (10–20) months after surgery. In these patients, the postoperative changes between the short-term and mid-term gait analyses were evaluated. Results: DFESO led to a significant decrease in flexed knee gait with an improvement in sagittal plane kinematics during the stance phase. In addition, a slightly increased anterior pelvic tilt was observed at E1, and we found a tendency towards stiff knee gait with a decrease in mean knee flexion in swing at E2. Conclusions: DFESO led to a significant improvement in flexed knee gait in children with cerebral palsy. The therapeutic effect seems to be lasting on mid-term follow-up with a slight overall tendency to recurrence.

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“…Research also notes unintended consequences of increased anterior pelvic tilt after distal femoral extension osteotomies, patella tendon shortening, HSL, hamstring transfers, and combination procedures. 6,7,9,[11][12][13][14] Increased anterior pelvic tilt is correlated with increased lumbar lordosis, back pain, and increased energy expenditure during gait 18 and is not part of the natural history of gait for children with CP, 19 making surgeons cautious about performing surgeries after which this can occur. ADFH has been growing in use for skeletally immature children with fixed knee flexion deformities and flexed knee gait, due to it being less invasive and having a shorter recovery time than distal femoral extension osteotomies.…”

mentioning

confidence: 99%

“…There are several surgical options in the treatment of fixed knee flexion deformities and flexed knee gait, including distal femoral extension osteotomy with or without patellar tendon shortening/advancement, 6–8 patella tendon shortening/advancement alone, 9,10 hamstring lengthening (HSL), 11,12 hamstring transfer, 13,14 anterior distal femoral hemiepiphysiodesis (ADFH), 15,16 or a combination of bony and soft tissue procedures 17 with improvement in static and dynamic knee extension reported. Research also notes unintended consequences of increased anterior pelvic tilt after distal femoral extension osteotomies, patella tendon shortening, HSL, hamstring transfers, and combination procedures 6,7,9,11–14 . Increased anterior pelvic tilt is correlated with increased lumbar lordosis, back pain, and increased energy expenditure during gait 18 and is not part of the natural history of gait for children with CP, 19 making surgeons cautious about performing surgeries after which this can occur.…”

mentioning

confidence: 99%

Anterior Distal Femoral Hemiepiphysiodesis Does Not Change Pelvic Tilt in Children With Cerebral Palsy

Hanson,

Wren,

Rethlefsen

et al. 2023

Journal of Pediatric Orthopaedics

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Background: Anterior distal femoral hemiepiphysiodesis (ADFH) is a surgical treatment choice to correct flexed knee gait and fixed knee flexion deformities in children with cerebral palsy who are skeletally immature. Increased anterior pelvic tilt has been reported after surgeries that correct knee flexion deformities, including hamstring lengthening (HSL) and distal femoral extension osteotomies, but anterior pelvic tilt has not been studied after ADFH. We hypothesized that anterior pelvic tilt would increase after ADFH, especially when combined with HSL, and it would correlate with the change in minimum knee flexion in stance and dynamic hamstring lengths. Methods: Thirty-four eligible participants (age: 13.0, SD: 2.0) were included. Change in mean pelvic tilt across the gait cycle was compared as a function of clinical and gait parameters using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation Results: Overall, anterior pelvic tilt increased significantly after ADFH by 4.4 degrees (P = 0.02). Further, the analysis revealed anterior pelvic tilt only increased significantly in the group that had concurrent HSL (11.1 degrees, P < 0.001). Overall, minimum knee flexion significantly decreased (increase in knee extension) in stance (−19.1 degrees, P < 0.001) and there was an increase in maximum normalized dynamic hamstring lengths (0.03, P < 0.001). The anterior pelvic tilt increased significantly in Gross Motor Function Classification System levels III to IV (5.9 degrees, P = 0.02) but did not change significantly in Gross Motor Function Classification System I to II (2.5 degrees, P = 0.37). Change in pelvic tilt was correlated with change in maximum dynamic hamstring lengths (r = 0.87, P < 0.0001) and change in minimum knee flexion in stance (r = −0.71, P < 0.0001). Conclusions: Anterior distal hemiepiphysiodesis without concurrent HSL for flexion knee deformities does not result in increased anterior pelvic tilt. Surgeons should consider anterior distal hemiepiphysiodesis in patients with cerebral palsy and flexed knee gait, who preoperatively have long dynamically modeled hamstrings, are skeletally immature, and when maintenance of pelvic tilt is desired. Level of Evidence: Level III—retrospective comparative study.

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The increase of anterior pelvic tilt after semitendinosus transfer to distal femur in patients with spastic diplegic cerebral palsy

Cited by 8 publications

References 20 publications

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

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

Mid-Term Results of Distal Femoral Extension and Shortening Osteotomy in Treating Flexed Knee Gait in Children with Cerebral Palsy

Anterior Distal Femoral Hemiepiphysiodesis Does Not Change Pelvic Tilt in Children With Cerebral Palsy

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