DISTANT EFFECTS OF HAMSTRING LENGTHENING IN PATIENTS WITH CEREBRAL PALSY

Radha Korupolu, MBBS, MS (PGY3)

Physical Medicine & Rehabilitation

University of Kentucky

Hank White,PT,PhD

Shriners Hospital for Children , Lexington, KY

BACKGROUND Hamstring lengthening (HL) surgery is commonly

performed in children with cerebral palsy (CP) to improve crouched gait.

However, there is a concern that this surgery may have undesirable side effects at distant joints.

The purpose of this study is to evaluate the distant joint effects of hamstring lengthening in subjects with crouched gait due to CP.

COMPLICATIONS FROM SURGERY

Nerve palsy

Genu recurvatum

Anterior pelvic tilt

Lumbar hyperlordosis

LITERATURE REVIEW

At this time, it is very difficult to study isolated

surgeries because multilevel surgery is the standard in

today’s treatment of the child with CP.

Outcomes of multilevel soft tissue surgery in 31 amb. children

w/ CP

Surgeries performed: Hamstrings lengthening Rectus transfer

TAL or Gastrocnemius aponeurotic lengthening

Time form surgery to post-op eval. average: 1.9 yrsPre-op Post-op p-value

Mean pelvic ant. Tilt (SD) 19 (6) 21 (6) 0.052

Mean Hip flexion at IC (SD) 47 (7) 46 (10) 0.627

Mean peak Hip flexion at SW (SD) 50 (8) 48 (10) 0.137

Temporal parameters Pre-op Post-op P-value

Mean Cadence, steps/min (SD) 136 (11)

128 (13) 0.000

Mean Stride length, cms (SD) 92 (11) 102 (14) 0.000

Mean Velocity, cms/sec (SD) 105 (16)

109 (17) 0.004

ADOLFSEN ET.AL.J PEDIATR ORTHOP. 2007 SEP;27(6):658-67..

M.S. PARK ET AL. / GAIT & POSTURE 30 (2009) 487–491

Retrospective study

CP with spastic diplegia, GMFCS 3

2 groups DHL + TAL (A) vs. DHL + TAL + RFT (B)

All subjects N=28

Group DHL + TAL N =8

Group DHL+TAL+RFT N =20

Pre-op Post-op p-value Pre-op Post-op p-value

Pre-op Post-op p-value

Pelvic tilt, mean 16.2 16.5 0.56 16 18.2 0.011 16.3 15.8 0.24

Max Hip flex at term. swing, mean

45.3 44.1 0.17 48.2 46.2 0.135 44.1 43.3 0.46

PARK ET AL./GAIT & POSTURE 37 (2013) 536–541

Retrospective study to eval. long term outcomes of single event multilevel surgeries including bilat. DHL

N = 28, ambulatory pts with CP spastic diplegia

Mean f/u time: 11.8 yrs

Single event multilevel procedures Intramuscular psoas lengthening Flexion Adductor tenotomy Distal hamstring lengthening Rectus femoris transfer Tendo achilles lengthening Femoral derotation osteotomy

OUTCOMES: MEAN VALUES

N =28 Pre-op Post-op

1 year

Post-op

10 years

p-value

post-op 1 yr

p-value

post-op 10 yr

Mean pelvic tilt 17.8 18.6 16.8 1.0 1.0

Maximum hip flexion in early stance

45.5 46.6 43.8 1.0 1.0

Maximum hip flexion in late swing

48.1 48.5 45.3 1.0 0.43

Cadence, steps/min 78.9 87.8 103 0.010 <0.001

Stride length, cm 105.9 99.1 100.2 0.136 0.582

Velocity, cms/sec 71.2 72.3 87.0 1.00 0.019

RESEARCH STUDY Goal: To study distant effects of hamstring

lengthening in children with CP

Design: Retrospective study

Sample size: 147 pts with spastic diplegia who had hamstring lengthening between 1993 and 2010

Outcomes: Pre-op & post-op pelvic, hip, ankle kinematics and

temopro-spatial parameters Computerized 3-dimensional gait analysis The paired samples t test was used to compare the

pre & post-op data.

GAIT CYCLE 0 % of gait cycle: Initial contact 30% of gait cycle: Mid-stance 60% of gait cycle: Toe-off 80% of gait cycle: Mid- swing

DESCRIPTIVE STATISTICS

No. (%)

Gender

Male 97 (66%)

Female 50 (34%)

GMFCS 1 26 (17.7%)

GMFCS 2 48 (32.7%)

GMFCS 3 73 (49.7%)

Mean(sd) Min Max

Age at surgery, years 12. 1 (3.2) 4 21

Duration b/w surgery & post op gait analysis, years

1.4 (1.1) 0.6 10.6

DESCRIPTIVE STATISTICS

No. (%)

Previous hamstring lengthening 34 (23.1%)

Simultaneous other procedures 113 (76%)

TAL 32 (21.8%)

Rectus transfer 30 (20.4%)

TAL & rectus transfer 30 (20.4%)

TAL, rectus transfer & other soft tissue 6 (4.1%)

TAL, rectus transfer & bony procedures 9 (6.1%)

Other soft tissue procedures 4 (2.7%)

Hardware removal 2 (1.4%)

Simultaneous rectus transfer 73 (49.7%)

RESULTS

RESULTS: EFFECT ON PELVIC TILT

RESULTS: EFFECT ON PELVIC TILT

Pre-op Post-op p-value

N Mean (SD) Mean (SD)

PELVIS_0 144 12.35 (7.99) 17.25 (8.86) <0.0001

PELVIS_30 144 15.89 (7.48) 20.26 (8.63) <0.0001

PELVIS_60 144 15.57 (7.88) 19.69 (8.71) <0.0001

PELVIS_80 144 16.36 (7.75) 20.15 (8.74) <0.0001

EFFECT ON PELVIC TILT W/ & W/O RECTUS TRANSFER

simultaneous rectus N Mean Std. D p-value

change_Pelvis_0no 71 6.4493 7.06

0.009yes 71 3.1746 7.64

change_Pelvis_30no 71 5.9237 6.61

0.006yes 71 2.5987 7.57

change_Pelvis_60no 71 5.7492 6.61

0.005yes 71 2.3985 7.33

change_Pelvis_80no 71 5.7000 6.91

0.001yes 71 1.7677 7.31

Decrease Increase > + 5° change > + 10° change

Change in pelvic tilt 0 23% 77% 48% 19%

Change in pelvis tilt 30 29% 71% 47% 18%

Change in pelvic tilt 60 27% 73% 45% 18%

Change in pelvic tilt 80 29% 70% 41% 17%

PELVIC TILT: MAGNITUDE

EFFECTS ON HIP FLEXION

EFFECTS ON HIP FLEXION

Pre-op Post-op

N Mean (SD) Mean (SD) p-value

RHip_0 144 46.01 (9.95) 44.99 (9.14) 0.32

RHip_30 144 24.96 (10.77) 23.39 (9.91) 0.17

RHip_60 144 15.51 (10.30) 14.97 (10.31) 0.62

RHip_80 144 35.84 (9.57) 35.72 (10.08) 0.812

EFFECTS ON ANKLE IN PATIENTS WITH HL ALONE

EFFECTS ON ANKLE IN PATIENTS WITH HL ALONE

R ankle kinematic for pts with HL alone

Pre-op Post-op p-value

N Mean (SD) Mean (SD)

R ankle 0% 73 3.97 (7.47) 1.27 (7.05) 0.03

R ankle 30% 73 11.64 (7.91) 7.93 (6.97) 0.004

R ankle 60% 73 0.28 (10.04) -1.69 (8.61) 0.21

R ankle 80% 73 4.93 (10.19) 3.72 (8.31) 0.43

EFFECTS ON TEMPORO-SPATIAL PARAMETERS

EFFECTS ON TEMPORO-SPATIAL PARAMETERS

n Pre-op Post-op p value

Cadence (steps/min) 144 110.17 103.36 0.02

Velocity (cm/s) 144 73.24 74.40 0.60

Stride length (cm) 144 78.66 85.21 0.01

CONCLUSION

Hamstring lengthening aggravates ant.pelvic tilt

Subjects with simultaneous rectus transfer & HL had less change in pelvic tilt compared to HL alone

No effects on hip flexion

HL when performed w/o TAL corrects excessive dorsi-flexion of ankle during IC and mid-stance

Improves velocity and stride length during gait

STUDY LIMITATIONS

Retrospective Study

Multiple simultaneous surgeries

Large variation in time to follow-up (6 mos -10

yrs)

H/o multiple previous surgeries

Pts may have multiple other interventions

between surgery & f/u time

FUTURE STUDIES

Long-term follow-up studies are necessary to assess the undesirable effects of HL on function

Subjects with > 10 degrees worsening of pelvic tilt ----- Functional status?

Did they require assistive devices?

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