1. Multiple Tendon Release of Lower Extremity for Cerebral Palsy Patients
M.Bülent BALİOĞLU, Özgür KORKMAZ, M.Akif KAYGUSUZ
MH Metİn SabancI BaltalİmanI Bone Disease
Education Hospital, İstanbul, TURKEY

2. Purpose
To evaluate the success of simultaneous multiple release of lower extremities of patients with spastic cerebral palsy (CP).
Special attention was given to flexion deformity of the knee, which is the most common deformity observed in the knee.
The purpose of our study was…

3. Purpose
We compared the pre-op and post-op popliteal angles (PA) and Gross Motor Function Measurement (GMFM) of CP patients who received multiple level lower extremity lengthening to evaluate the effect of surgery and patient satisfaction.

4. Background Hamstrings are nearly always affected in patients with CP.
Hamstrings cross two joints, the hip and the knee.
Hamstrings serve as hip extensors at the hip, and at the knee they serve as knee flexors.
…they…and they…

5. Background Hamstring spasticity can be measured with PA.
Holt’s method of determining hamstring contracture.
..here is a picture of Holt’s method

6. Background
In healthy children 4 years and older there is variability in normal PA, with a mean value of 26°.
Values greater than 50° in this age range are considered abnormal.

7. Background
A fixed knee flexion contracture may develop in severe hamstring contractures.
Assessment for a fixed contracture is necessary as such a contracture may lead to complications after hamstring lengthening.

8. Background
GMFM is a scoring system that separates CP patients into five functional levels.

9. Background
Level 1: a child who can run, walk, and climb stairs but has mild impairments in speed and balance.
Level 5: a child who depends on others for mobility, uses a wheelchair, and has no control of head or trunk.

10. Materials and Methods
We performed multiple level lower extremity tendon lengthening for 6 CP patients with a mean age of 9.1 years (5 - 15) between 2001 and 2005.
The average follow up was 57.3 months (43-76).

11. Materials and Methods
12 lower extremities of 6 patients (3 male, 3 female) received lengthening operations.
Long term results of all patients were evaluated to control success of simultaneous multiple release of lower extremities.

12. Materials and Methods
Hamstring, rectus femoris, iliopsoas, adductor tenotomies, tenolysis w/wo achiloplasty for both lower extremities were released simultaneously.

13. Materials and Methods
Circular casts were applied to all patients’ lower extremities.
Casts were removed 15 days postop and we began phyisiotherapy and rehabilitation with KAFO.
Then…

14. Materials and Methods
GMFM and pre versus post operative PA were used for evaluation.

15. Results GMFM values Pre-op 1 patient Level 5 4 patients Level 3
Post-op
1 patient
Level 3
3 patients
Level 2
2 patiensts
Level 1
Here we have a list of….all patients improved postoperatively.

16. Results
Post-operative GMFM values were lower than pre-operative values (p<0.05).
GMFM
Pre op
Post op
Level 1 0% 2
33,3%
Level 2 1
16,7% 3
50%
Mc Nemar’s
Level 3 4
66,7%
p=0,039
Level 5
As you can see…

17. Results
PA decreased post-operatively from a mean pre-op angle of 59° (45-70) to a post-op PA average of 45° (20-65).
Preop (°)
Preop SD
Postop (°)
Postop SD
Popliteal Angles 59
45-70 45
20-65

18. Results Patient Initials PA (°) GMFM (Level) Follow up (month) Preop
Postop
Pre-op
Post-op R L
HZM 70 60 40 50 3 2 76 FY 1 CC ÜY 45 43 AY 5 65 RY 30 20
59 (45-70)
45 (20-60)
57.3 (43-76)
Popliteal angles and GMFM levels and follow up durations are shown here.

19. Results Post-op Pre-op ÜY (♀) 16 y PA (◦) GMFM Follow up (month) R L60 70 3 43
Postop 50 45 2
Post-op
In the following slides we can see the popliteal angles, GMFM scores and visual results of a few patients from our study. A 16 year old patient…
Pre-op

20. Results
SE (♂) PA
GMFM
Follow up R L
Preop
Postop
Pre-op
Post-op

21. Results Post-op Pre-op RY (♂) 11 y PA (◦) GMFM Follow up (month) R L60 45 2
Postop 30 20 1
Post-op
Late Post-op
Pre-op
For example a male patient current age 11. Follow-up period 60 months and the preop and postop pictures and results.
Early Post-op

22. Results HZM (♀) 14 y PA (◦) GMFM Follow up (month) R L Preop 70 60 376
Postop 40 50 2
Preop
Here we have a female patient, age 14,
Early Post-op
Late Post-op

23. Results Pre-op Post-op HŞ (♂) PA GMFM Follow up R L Preop Postop
In this slide…
Post-op

24. Results Pre-op Post-op FY (♂) 14 y PA (◦) GMFM Follow up (month) R L60 3
Postop 40 1
Pre-op
Post-op

25. Results Pre-op Late Post-op Early Post-op AY (♂) 16 y PA (◦) GMFM
Follow up (month) R L
Preop 50 70 5 65
Postop 60 3
Pre-op
Late Post-op
Early Post-op

26. Results Pre-op Post-op CC (♀) 12 y PA (◦) GMFM Follow up (month) R L70 3 40
Postop 60 2
Pre-op
Post-op
And finally…a 12 year old female paitent…

27. Conclusion
Many different methods are used to assess the surgical and conservative treatment of CP patients.
Gait analysis
GMFM
WEE-FIM (a pediatric measure of functional independence)
PODCI (Pediatric Outcomes Data Collection Instrument)

28. Conclusion
In our study we used GMFM and PA to evaluate multiple tendon release lengthening of CP patients.
GMFM scores showed that all multiple tendon releases of lower extremities in CP patients was successful.

29. Conclusion
With regards to flexion deformity of the knee, the changes in the PA were positive.
The most important factor in preventing knee flexion deformity after surgery is appropriate physical therapy and bracing.

30. Conclusion
Both methods were practical and cost effective for postop assessment and long term evaluation and useful in terms of evaluating patient satisfaction. .

31. THANK YOU