D ISTANT EFFECTS OF H AMSTRING L ENGTHENING IN P ATIENTS WITH C EREBRAL P ALSY Radha Korupolu, MBBS, MS (PGY3) Physical Medicine & Rehabilitation University.

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D ISTANT EFFECTS OF H AMSTRING L ENGTHENING IN P ATIENTS WITH C EREBRAL P ALSY Radha Korupolu, MBBS, MS (PGY3) Physical Medicine & Rehabilitation University of Kentucky Hank White,PT,PhD Shriners Hospital for Children, Lexington, KY

B ACKGROUND 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.

C OMPLICATIONS FROM S URGERY Nerve palsy Genu recurvatum Anterior pelvic tilt Lumbar hyperlordosis

L ITERATURE 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 yrs Pre-opPost-opp-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 parametersPre-opPost-opP-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 A DOLFSEN A DOLFSEN ET. AL.J P EDIATR O RTHOP S EP ;27(6): J P EDIATR O RTHOP.

M.S. P ARK ET AL. / G AIT & P OSTURE 30 (2009) 487–491 Retrospective study CP with spastic diplegia, GMFCS 3 2 groups DHL + TAL (A) vs. DHL + TAL + RFT (B)

P ARK ET AL./G AIT & P OSTURE 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

O UTCOMES : M EAN VALUES

R ESEARCH S TUDY 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.

G AIT 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

D ESCRIPTIVE STATISTICS No. (%) Gender Male97 (66%) Female50 (34%) GMFCS 126 (17.7%) GMFCS 248 (32.7%) GMFCS 373 (49.7%) Mean(sd)MinMax Age at surgery, years12. 1 (3.2)421 Duration b/w surgery & post op gait analysis, years 1.4 (1.1)

D ESCRIPTIVE STATISTICS No. (%) Previous hamstring lengthening34 (23.1%) Simultaneous other procedures113 (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 transfer73 (49.7%)

R ESULTS

R ESULTS : E FFECT ON PELVIC TILT

E FFECT ON PELVIC TILT W / & W / O RECTUS TRANSFER simultaneous rectus NMeanStd. Dp-value change_Pelvis_0 no yes change_Pelvis_30 no yes change_Pelvis_60 no yes change_Pelvis_80 no yes

P ELVIC TILT : M AGNITUDE

E FFECTS ON H IP F LEXION

Pre-opPost-op NMean (SD) p-value RHip_ (9.95)44.99 (9.14) 0.32 RHip_ (10.77)23.39 (9.91)0.17 RHip_ (10.30)14.97 (10.31)0.62 RHip_ (9.57)35.72 (10.08)0.812

E FFECTS ON A NKLE IN PATIENTS WITH HL ALONE

R ankle kinematic for pts with HL alone Pre-opPost-opp-value NMean (SD) R ankle 0% (7.47)1.27 (7.05)0.03 R ankle 30% (7.91)7.93 (6.97)0.004 R ankle 60% (10.04)-1.69 (8.61)0.21 R ankle 80% (10.19)3.72 (8.31)0.43

E FFECTS ON T EMPORO - SPATIAL PARAMETERS

nPre-opPost-opp value Cadence (steps/min) Velocity (cm/s) Stride length (cm)

C ONCLUSION 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

S TUDY L IMITATIONS 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

F UTURE S TUDIES 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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