1. Ki Hyuk Sung, MD Department of Orthopaedic Surgery Seoul National University Bundang Hospital Long term outcome of SEMLS including DHL in spastic diplegia

2. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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

3. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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.

4. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Purpose To investigate the long term outcome of SEMLS including DHL in patients with CP (GMFCS level I-III) Focus on the kinematic changes

5. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Material and methods

6. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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

7. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Exclusion criteria Concurrent neuromuscular disease History of gait correcting surgery History of dorsal rhizotomy

8. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Operative protocols Single event multilevel surgery by one surgeon Base on both clinical and gait analysis findings Standard postsurgical care including casting or bracing

9. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Surgical principles of procedures ProcedureClinical CriteriaGait Analysis Criteria Intramuscular psoas lengtheningFlexion contracture >15 degreesDecreased hip extension Adductor tenotomyHip abduction <20 degreesDecreased hip abduction Distal hamstring lengtheningIncreased popliteal angle Decreased knee flexion at initial contact/terminal swing Rectus femoris transferDuncan-Ely test (+) Decreased/delayed peak knee flexion Tendo Achilles lengthening Equinus deformity with Silfverskiöld test (-) Decreased dorsiflexion in stance, abnormal rocker, and foot drop in swing Strayer procedure Equinus deformity with Silfverskiöld test (+) Decreased dorsiflexion in stance and abnormal rocker Femoral derotation osteotomyIncreased femoral anteversion Internal foot progression with increased hip internal rotation

10. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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

11. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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

12. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Results

13. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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 examinationLeftRight Popliteal angle (˚)54.4±20.754.3±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)1714

14. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Summary of surgical procedures Surgical procedures No. at 1st operation No. at 2nd operation No. at 3rd operation Total No. Femoral derotation osteotomy302032 Distal hamstring lengthening5815073 Adductor tenotomy126018 Rectus femoris transfer2911040 Intramuscular psoas lengthening 122014 TAL, Strayer or Vulpius466254 Calcaneal lengthening162119 TDO or TRO2406 Others*81211 Total213(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.

15. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Temporal parameters after SEMLS Preoperative Postoperative (1 years) Postoperative (10 years) p-value RM- ANOVA Preop-1YPreop-10Y1Y-10Y Stride length (cm) 78.9 (23.4)87.8 (16.5)103.0 (15.0)<0.001*0.010<0.001 Cadence (steps/min) 105.9 (22.0)99.1 (16.6)100.2 (17.9)0.136 0.5821.000 Walking Speed (cm/s) 71.1 (25.4)72.3 (17.4)87.0 (23.1)0.002*1.0000.0190.001

16. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Pelvis and hip Kinematic parameters Preoperative Postoperative (1 years) Postoperative (10 years) p-value RM- ANOVA Preop-1YPreop-10Y1Y-10Y Mean pelvic tilt ( ˚) 17.8 (7.9)18.6 (6.8)16.8 (6.3)0.3931.000 0.344 Minimum hip flexion ( ˚) -0.9 (9.4)-2.5 (9.7)1.8 (8.1)0.1141.0000.5440.147 Mean hip adduction ( ˚) -1.7 (6.1)-1.8 (4.3)-0.1 (4.1)0.2481.0000.5000.104 Mean hip rotation ( ˚) 10.1 (19.1)4.4 (13.6)-1.0 (7.7)0.012*0.4840.0100.239

17. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Knee kinematic parameters Preoperative Postoperative (1 years) Postoperative (10 years) p-value RM- ANOVA Preop-1YPreop-10Y1Y-10Y Knee flexion at initial contact ( ˚) 31.1 (12.7)26.0 (7.6)23.6 (8.1)0.011*0.0650.0380.400 Minimum knee flexion in stance ( ˚) 7.6 (13.8)2.7 (9.8)7.3 (10.6)0.1140.1101.0000.187 Peak knee flexion in swing ( ˚) 55.3 (15.8)57.6 (10.1)57.4 (7.6)0.6211.000 Knee range of motion ( ˚) 47.7 (14.3)54.9 (13.0)50.2 (12.0)0.0670.0781.0000.432

18. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL Ankle and foot kinematic parameters Preoperative Postoperative (1 years) Postoperative (10 years) p-value RM- ANOVA Preop-1YPreop-10Y1Y-10Y Ankle dorsiflexion at initial contact ( ˚) 1.8 (10.0)7.1 (10.8)1.2 (6.4)0.007*0.0591.0000.011 Peak ankle dorsiflexion in stance ( ˚) 16.7 (14.1)18.6 (11.9)14.7 (7.2)0.2821.000 0.228 Peak ankle dorsiflexion in swing ( ˚) 9.8 (17.2)14.5 (14.0)7.1 (6.6)0.05*0.4691.0000.017 Mean foot progression in stance ( ˚) 0.2 (18.9)-8.9 (11.0)-9.7 (9.9)0.001*0.0110.0071.000

19. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL GDI after SEMLS Preoperative Postoperative (1 years) Postoperative (10 years) p-value RM- ANOVA Preop-1YPreop-10Y1Y-10Y 69.4 (11.3)77.9 (9.5)82.2 (8.9)<0.001*0.003<0.0010.017

20. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL 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

21. SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL ◦ SEOUL NATIONAL UNIVERSITY BUNDANG HOSPITAL