1. 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

2. 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.

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

4. 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.

5. 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. 2007 S EP ;27(6):658-67..J P EDIATR O RTHOP.

6. 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)

7. 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

8. O UTCOMES : M EAN VALUES

9. 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.

10. 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

11. 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)0.610.6

12. 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%)

13. R ESULTS

14. R ESULTS : E FFECT ON PELVIC TILT

16. E FFECT ON PELVIC TILT W / & W / O RECTUS TRANSFER simultaneous rectus NMeanStd. Dp-value change_Pelvis_0 no716.44937.06 0.009 yes713.17467.64 change_Pelvis_30 no715.92376.61 0.006 yes712.59877.57 change_Pelvis_60 no715.74926.61 0.005 yes712.39857.33 change_Pelvis_80 no715.70006.91 0.001 yes711.76777.31

17. P ELVIC TILT : M AGNITUDE

18. E FFECTS ON H IP F LEXION

19. Pre-opPost-op NMean (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

20. E FFECTS ON A NKLE IN PATIENTS WITH HL ALONE

21. R ankle kinematic for pts with HL alone Pre-opPost-opp-value NMean (SD) R ankle 0%733.97 (7.47)1.27 (7.05)0.03 R ankle 30%7311.64 (7.91)7.93 (6.97)0.004 R ankle 60%730.28 (10.04)-1.69 (8.61)0.21 R ankle 80%734.93 (10.19)3.72 (8.31)0.43

22. E FFECTS ON T EMPORO - SPATIAL PARAMETERS

23. nPre-opPost-opp value Cadence (steps/min)144110.17103.360.02 Velocity (cm/s)14473.2474.400.60 Stride length (cm)14478.6685.210.01

24. 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

25. 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

26. 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?

27. R EFERENCES 1. Herring JA, Tachdjian MO. Texas Scottish Rite Hospital for Children. Tachdjian’s Pediatric Orthopaedics. 4 th Edition. Philadelphia: Saunders/ Elsevier; 2008 2. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy. Dev Med Child Neurol Suppl. 2007;109:8–14. 3. Gordon AB, Baird GO, McMulkin ML, Caskey PM, Ferguson RL. Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy. Journal of Pediatric Orthopaedics 2008;28(3):324–9. 4. Unnithan VB, Dowling JJ, Frost G, Bar-Or O. (1999) Role of mechanical power estimates in the O2 cost of walking in children with cerebral palsy. Med Sci Sports Exer 31: 1703–1708. 5. Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 11 th Edition. Accessed Online. 6. Dhawlikar SH, Root L, Mann RL. Distal lengthening of the hamstrings in patients who have cerebral palsy. Long-term retrospective analysis. J Bone Joint Surg Am. 1992 Oct;74(9):1385-91. Dhawlikar SHRoot LMann RLJ Bone Joint Surg Am. 7. S. L. Delp, A. S. Arnold, R. A. Speers, and C. A. Moore, "Hamstrings and psoas lengths during normal and crouch gait: implications for muscle-tendon surgery," Journal of Orthopaedic Research, vol. 14, pp. 144-151, 1996. 8. DeLuca P, Ounpuu O, Davis RB, Walsh J: Effect of hamstrings and psoas lengthening on pelvic tilt in patients with spastic diplegic cerebral palsy. Journal of Pediatric Orthopaedics 1998, 18:712-718. 9. Gage JR, Novacheck TF. (2001) An update on the treatment of gait problems in cerebral palsy. J Pediatr Orthop B 10: 265–274. 10. B.T. Carney, D. Oeffinger and A.M. Meo, Sagittal knee kinematics after hamstring lengthening, J Pediatr Orthop B 15 (5) (2006), pp. 348–350. 11. J.R. Gage and T.F. Novacheck, An update on the treatment of gait problems in cerebral Palsy, J Pediatr Orthop 10 (Part B) (2001), pp. 265–274 12. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galappi B.(1997) Development and reliability of a system to classify grossmotor function in children with cerebral palsy. Dev Med Child Neurol 39: 214–223. 13. Chang WN, Tsirikos AI, Miller FM, Lennon N, Schuyler J, Kerstetter L, Glutting J,. Distal Hamstring Lengthening in ambulatory children with Cerebral palsy: primary versus revision procedures. Gait and Posture. (2004) 19: 298-304 14. Schwartz MH, Viehweger E, Stout J, Novacheck TF, Gage JR. Comprehensive treatment of ambulatory children with cerebral palsy: an outcome assessment. Journal of Pediatric Orthopedics 2004;24:45–53.

28. Questions???