Ki Hyuk Sung, MD

Department of Orthopaedic SurgerySeoul National University Bundang Hospital

Long term outcome of SEMLS including DHL in spastic diplegia

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Introduction

• Distal hamstring lengthening (DHL)

commonly performed procedure in flexed knee gait

Effective at reducing knee flexion and improving knee

motion

Concern on adverse effect ( increased pelvic tilt, lumbar

hyperlordosis, genu recurvatum, crouch gait) in long term

follow up

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Introduction

• Few studies about the long-term effects of SEMLS with

DHL in spastic diplegia.

• It is questionable whether functional improvements after

surgery are maintained into adulthood.

• It is questionable how long improvements last.

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Purpose

• To investigate the long term outcome of

SEMLS including DHL in patients with CP

(GMFCS level I-III)

• Focus on the kinematic changes

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Material and methods

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Inclusion criteria

• Ambulatory patients with spastic diplegic

cerebral palsy (GMFCS level I-III)

• Patients who underwent SEMLS including

bilateral DHL

• Patients who had preoperative, 1-year

postoperative, and 10-year postoperative 3D gait

analysis

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Exclusion criteria

• Concurrent neuromuscular disease

• History of gait correcting surgery

• History of dorsal rhizotomy

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Operative protocols

• Single event multilevel surgery by one surgeon

• Base on both clinical and gait analysis findings

• Standard postsurgical care including casting or

bracing

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Surgical principles of procedures

Procedure Clinical Criteria Gait Analysis Criteria

Intramuscular psoas lengthening Flexion contracture >15 degrees Decreased hip extension

Adductor tenotomy Hip abduction <20 degrees Decreased hip abduction

Distal hamstring lengthening Increased popliteal angleDecreased knee flexion at initial contact/terminal swing

Rectus femoris transfer Duncan-Ely test (+)Decreased/delayed peak knee flexion

Tendo Achilles lengtheningEquinus deformity with Silfverskiöld test (-)

Decreased dorsiflexion in stance, abnormal rocker, and foot drop in swing

Strayer procedureEquinus deformity with Silfverskiöld test (+)

Decreased dorsiflexion in stance and abnormal rocker

Femoral derotation osteotomy Increased femoral anteversionInternal foot progression withincreased hip internal rotation

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Acquisition of data

• 3D gait analysis

• Preoperative

• 1 year postoperative

• Over 10 year postoperative

• Kinematic parameter, temporal parameter, GDI

• Comparison using repeated measures analysis of

variance (ANOVA) with a Boneferroni post hoc test

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GDI (gait deviation index)

• Represent overall gait pathology

• Correlated with GGI, FAQ, GMFM

• Pelvic and hip kinematic data in three plane, knee

and ankle data in sagittal plane, and foot

progression

• GDI score≥100 denote a non-pathological gait

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Results

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Dermographics and preop P/Ex

Gender (M:F) 18:11

Mean age at first surgery in years (range) 8.3±2.6 (5.4-16.3)

Mean age at second surgery in years (range) 12.1±4.3 (7.3-21.8)

Mean follow-up years (range) 11.8±1.1 (10.0-13.3)

Mean age at last follow-up in years (range) 20.1±3.0 (15.9-26.8)

GMFCS (I/II/III) 7/19/3

Preoperative physical examination Left Right

Popliteal angle (˚) 54.4±20.7 54.3±22.8

Ankle dorsiflexion at knee extension (˚) -10.5±10.3 -10.7±11.0

Ankle dorsiflexion at 90˚ knee flexion (˚) -4.8±10.1 -8.1±11.0

Ely test (positive) 17 14

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Summary of surgical procedures

Surgical proceduresNo. at 1st operation

No. at 2nd operation

No. at 3rd operation

Total No.

Femoral derotation osteotomy

30 2 0 32

Distal hamstring lengthening 58 15 0 73

Adductor tenotomy 12 6 0 18

Rectus femoris transfer 29 11 0 40

Intramuscular psoas lengthening

12 2 0 14

TAL, Strayer or Vulpius 46 6 2 54

Calcaneal lengthening 16 2 1 19

TDO or TRO 2 4 0 6

Others* 8 1 2 11

Total 213(7.3) 49(1.7) 5(0.2) 267 (9.1)

Procedures per patient are given in parentheses.TAL, Tendo Achilles lengthening; TDO, Tibial derotation osteotomy; TRO, Tibial rotation osteotomy.* Others includes shelf acetabuloplasty, tibialis anterior tendon aponeurotic lengthening, tibialis posterior tendon aponeurotic lengthening.

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Temporal parameters after SEMLS

PreoperativePostoperative

(1 years)Postoperative

(10 years)

p-value

RM-ANOVA

Preop-1Y Preop-10Y 1Y-10Y

Stride length (cm)

78.9 (23.4) 87.8 (16.5) 103.0 (15.0) <0.001* 0.010 <0.001 <0.001

Cadence (steps/min)

105.9 (22.0) 99.1 (16.6) 100.2 (17.9) 0.136 0.136 0.582 1.000

Walking Speed (cm/s)

71.1 (25.4) 72.3 (17.4) 87.0 (23.1) 0.002* 1.000 0.019 0.001

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Pelvis and hip Kinematic parameters

PreoperativePostoperative

(1 years)Postoperative

(10 years)

p-value

RM-ANOVA

Preop-1Y Preop-10Y 1Y-10Y

Mean pelvic tilt (˚)

17.8 (7.9) 18.6 (6.8) 16.8 (6.3) 0.393 1.000 1.000 0.344

Minimum hip flexion (˚)

-0.9 (9.4) -2.5 (9.7) 1.8 (8.1) 0.114 1.000 0.544 0.147

Mean hip adduction (˚)

-1.7 (6.1) -1.8 (4.3) -0.1 (4.1) 0.248 1.000 0.500 0.104

Mean hip rotation (˚)

10.1 (19.1) 4.4 (13.6) -1.0 (7.7) 0.012* 0.484 0.010 0.239

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Knee kinematic parameters

PreoperativePostoperative

(1 years)Postoperative

(10 years)

p-value

RM-ANOVA

Preop-1Y Preop-10Y 1Y-10Y

Knee flexion at initial contact (˚)

31.1 (12.7) 26.0 (7.6) 23.6 (8.1) 0.011* 0.065 0.038 0.400

Minimum knee flexion in stance (˚)

7.6 (13.8) 2.7 (9.8) 7.3 (10.6) 0.114 0.110 1.000 0.187

Peak knee flexion in swing (˚)

55.3 (15.8) 57.6 (10.1) 57.4 (7.6) 0.621 1.000 1.000 1.000

Knee range of motion (˚)

47.7 (14.3) 54.9 (13.0) 50.2 (12.0) 0.067 0.078 1.000 0.432

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Ankle and foot kinematic parameters

PreoperativePostoperative

(1 years)Postoperative

(10 years)

p-value

RM-ANOVA

Preop-1Y Preop-10Y 1Y-10Y

Ankle dorsiflexion at initial contact (˚)

1.8 (10.0) 7.1 (10.8) 1.2 (6.4) 0.007* 0.059 1.000 0.011

Peak ankle dorsiflexion in stance (˚)

16.7 (14.1) 18.6 (11.9) 14.7 (7.2) 0.282 1.000 1.000 0.228

Peak ankle dorsiflexion in swing (˚)

9.8 (17.2) 14.5 (14.0) 7.1 (6.6) 0.05* 0.469 1.000 0.017

Mean foot progression in stance (˚)

0.2 (18.9) -8.9 (11.0) -9.7 (9.9) 0.001* 0.011 0.007 1.000

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GDI after SEMLS

PreoperativePostoperative

(1 years)Postoperative

(10 years)

p-value

RM-ANOVA

Preop-1Y Preop-10Y 1Y-10Y

69.4 (11.3) 77.9 (9.5) 82.2 (8.9) <0.001* 0.003 <0.001 0.017

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Conclusion

• SEMLS including DHL provides favorable outcomes

10 years postoperatively in patient with spastic

diplegic cerebral palsy

• DHL is an effective procedure in flexed knee gait

without increasing pelvic tilt

• Considerable risk of equinus deformity recurrence

should be taken into consideration

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