d istant effects of h amstring l engthening in p atients with c erebral p alsy radha korupolu, mbbs,...
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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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