Factors related to better outcomes after single-event multilevel surgery (SEMLS) in patients with cerebral palsy.

BACKGROUND: Good outcomes have been described after single-event multilevel surgery (SEMLS) in cerebral palsy (CP); however, there is limited evidence regarding factors influencing them. RESEARCH QUESTION: What were the factors related to kinematic outcomes after SEMLS in the present study? METHODS: Two hundred and fifty-eight patients with spastic diplegic CP, GMFCS I-III, who underwent SEMLS and had done pre and post-operative gait analyses were included in the SEMLS Group (SEMLS-G). A second search was performed in the same database looking for patients to compose the Control Group (CG), and 88 subjects, with at least two gait analyses and with no surgical intervention between tests, were identified. Demographic data, GDI and GPS (Gait Profile Score) were analyzed in both groups, and the results compared. A second evaluation was performed in the SEMLS-G in order to identify the influence of age, gender, follow-up time, pre-operative GDI, GMFCS and gait velocity on results. RESULTS: The GDI (51.3-58.4) and GPS (2.5°) improvement occurred only in SEMLS-G (p < 0.001). On sagittal plane, there was an improvement at the knee and ankle levels in SEMLS-G, whereas the pelvic alignment improved in the CG. In SEMLS-G, patients with improvement on GDI > 10 points had lower pre-operative GDI (46.15) than other groups (p < 0.001). In addition, patients with reduction on GDI after intervention had lower pre-operative gait velocity than subjects with improvement >10 points (p = 0. 01). The increase on GDI after SEMLS was greater in patients GMFCS I and II than GMFCS III (p = 0.003). There was a negative effect of GMFCS III on GDI improvement after intervention (p = 0.014). SIGNIFICANCE: Lower pre-operative GDI, higher baseline gait velocity and GMFCS levels I and II were related to better outcomes after SEMLS in the present study. On the other hand, patients GMFCS III were more susceptible to deteriorate after SEMLS.

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

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.

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

The aim of this study was to compare semitendinosus transfer to distal femur (STTX) to semitendinosus surgical lengthening (STL) regarding the increase of anterior pelvic tilt after flexed knee gait treatment. Thirty-nine patients were evaluated, and they were divided according surgical procedures at knees: STL group (22 patients/44 knees), which included patients who received medial hamstrings surgical lengthening as part of multilevel approach, and STTX group (17 patients/34 knees), which was represented by patients who underwent orthopedic surgery including a STTX instead of STL. In the present study, the mean anterior pelvic tilt increased in all groups after treatment and STTX was not effective to prevent it in a medium-term follow-up.

Does the GMFCS level influence the improvement in knee range of motion after rectus femoris transfer in cerebral palsy?

The aim of this study was to evaluate the influence of the Gross Motor Function Classification System (GMFCS) on the outcomes of rectus femoris transfer (RFT) for patients with cerebral palsy and stiff knee gait. We performed a retrospective review of patients seen at our gait laboratory from 1996 to 2013. Inclusion criteria were (i) spastic diplegic cerebral palsy, (ii) GMFCS levels I-III, (iii) reduced peak knee flexion in swing (PKFSw<55°), and (iv) patients who underwent orthopedic surgery with preoperative and postoperative gait analysis. Patients were divided into two groups according to whether they received a concurrent RFT or not at the time of surgery: non-RFT group (185 knees) and RFT group (123 knees). The primary outcome was the overall knee range of motion (KROM) derived from gait kinematics. The secondary outcomes were the PKFSw and the time of peak knee flexion in swing (tPKFSw). We observed a statistically significant improvement in KROM only for patients in the RFT group (P<0.001). However, PKFSw and tPKFSw improved in both groups after surgery (P<0.001 for all analyses). In the RFT group, the improvement in KROM was observed only for patients classified as GMFCS levels I and II. In the non-RFT group, no improvement in KROM was observed in any GMFCS level. In this study, patients at GMFCS levels I and II were more likely to benefit from the RFT procedure.

Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy.

PURPOSE: The purpose of this study was to evaluate the results of distal femur extension osteotomy and medial hamstring lengthening in the treatment of fixed knee flexion deformity in patients with spastic diparetic cerebral palsy. METHODS: A retrospective study was done in a group of 12 diparetic cerebral palsy patients. A distal femur extension osteotomy was performed as part of multilevel surgery on lower limbs. The fixed knee flexion deformity was measured during physical examination, whereas hip and knee flexion in the stance phase and anterior pelvic tilt were both analyzed at kinematics. The pre- and post-surgery results were compared and analyzed statistically. A medical record review was done in order to identify the complications. The mean follow-up was 28 months. RESULTS: A significant reduction of fixed knee flexion deformity at physical examination and knee flexion in the stance phase at kinematics was observed, but with no decrease in hip flexion. As a non-desired effect, there was an increase in anterior pelvic tilt after surgical procedures. With regard to complications, a single patient had skin breakdown at a calcaneous area on one side and the recurrence of deformity was seen in 27% of cases. CONCLUSIONS: In this study, in which fixed knee flexion deformity did not exceed 40 degrees before surgery, the distal femur extension osteotomy was effective in increasing knee extension in the stance phase. However, an increase in anterior pelvic tilt, deformity recurrence and necessity for walking aids are possible complications of this procedure.

Efeitos da transferência do reto femoral e do alongamento dos isquiotibiais sobre a marcha de pacientes com paralisia cerebral / Effects of rectus femoris transfer and hamstrings lengthening on the gait cerebral palsy patients

Objetivo: Avaliar a influência do alongamento cirúrgico dos isquiotibiais mediais sobre o arco de movimento dos joelhos quando este procedimento foi combinado com a transferência do reto femoral. Métodos: Vinte e quatro pacientes com paralisia cerebral tipo diparesia espástica foram analisados de maneira retrospectiva. Os pacientes que foram submetidos à transferência do reto femoral para flexor de joelho sem o concomitante alongamento dos isquiotibiais mediais (n = 12) formaram o grupo A, enquanto que o grupo B (n = 12) foi constituído por pacientes em que estes procedimentos foram combinados. Todos foram submetidos à análise tridimensional da marcha antes e após a realização dos procedimentos cirúrgicos, com tempo de seguimento médio de 15,5 meses. Resultados: Houve aumento significativo e semelhante no arco de movimento dos joelhos em ambos os grupos após a realização dos procedimentos cirúrgicos. O aumento do pico de flexão na fase de balanço foi estatisticamente significante apenas no grupo A (aumento de 10,97°), porém foi observado aumento da flexão (de 10,53° para 14,71 °) na fase de apoio no exame pós-operatório. No grupo B foi observada redução da flexão no apoio e aumento do pico de flexão no balanço, porém ambos não significativos em termos estatísticos. Conclusão: Na amostra estudada, houve aumento significativo do arco de movimento dos joelhos após a realização dos procedimentos cirúrgicos, porém o alongamento dos isquiotibiais mediais não gerou aumento adicional.

Effects of intramuscular psoas lengthening on pelvic and hip motion in patients with spastic diparetic cerebral palsy.

The effects of intramuscular psoas lengthening on gait in cerebral palsy patients have been the subject of debates, and the indications for such procedure are still controversial. The purpose of this study was to evaluate the effects of intramuscular psoas lengthening on sagittal plane pelvic and hip motion in patients with spastic diparetic cerebral palsy and identify the factors linked to the best possible outcome. A retrospective study was performed in 26 independent ambulatory patients. All of them had undergone an intramuscular psoas lengthening over the pelvic brim. The mean age at the time of surgery was 11.10 years, and most cases went through additional simultaneous procedures. A complete gait analysis was performed before and, on average, at 17.69 months (range, 6-39 months) after surgery. The Thomas test values, maximum hip extension in stance, and pelvic tilt were analyzed before and after surgical intervention, and the results were statistically compared. The most significant postoperative effect was the reduction of pelvic range of motion (P < 0.01). Reduction of anterior pelvic tilt was observed only in those patients with no previous need of an external aid (P < 0.01), and the studied group did not show a significant improvement of hip extension at terminal stance. According to the results, intramuscular psoas lengthening was useful in reducing pelvic range of motion at the sagittal plane, but this study also suggests that pelvic and hip disruptions of the same plane (sagittal) seem to have a multifactorial etiology. The use of external assistive devices in patients with balance problems may lead to increased anterior pelvic tilt as well as reduction of hip extension at terminal stance.