Long-term outcome of hamstring lengthening versus transfer and the role of biceps femoris lengthening in patients with spastic diplegia and dynamic knee flexion in gait

Background:Orthopedic treatment of flexed-knee gait consists of hamstring lengthening along with surgery at other levels. Transfer of the semitendinosus (hamstring transfer) was introduced to avoid increase of anterior pelvic tilt as well as reduce risk of recurrence.Methods:We retrospectively assessed children with spastic cerebral palsy and flexed-knee gait pre-operatively, 1 year post-operatively, and at a minimum of 7 years post-operatively.Results:The 39 patients were a mean 9.4 ± 3.4 years at the time of surgery, 20 subjects underwent hamstring transfer, and 19 subjects had hamstring lengthening with mean follow-up 9.1 years. Passive range of motion improved initially, but regressed at long term. Dynamic minimum knee flexion in stance decreased in both groups at the first post-operative study, and was maintained at final follow-up in 64-67% of patients. There was a small increase in anterior pelvic tilt at the 1-year follow-up which subsequently decreased to less than pre-operative in the hamstring lengthening group but remained mildly increased (5°) in the hamstring transfer group at final follow-up. Success in correcting stance knee flexion of the entire group was 69% of the Gross Motor Function Classification System grades I and II and 60% of the Gross Motor Function Classification System grade III subjects. Gait profile Score and sagittal knee Gait Variable Score both showed clinically important improvement after surgery and was mostly maintained long term for both groups. Lateral hamstring lengthening was beneficial in more severe patients, with minimal risk of adverse effects.Conclusion:Hamstring surgery as part of single event multi-level surgery (SEMLS) is effective in correcting flexed-knee gait in 60%–70% of patients with minimal effect on anterior pelvic tilt. There was no added advantage to hamstring transfer. Biceps Femoris lengthening may be beneficial and without significant additional risk.Level of evidence:level III.     

改良手术治疗脑瘫痉挛性双侧下肢瘫

[目的]2004年以来对重症脑瘫痉挛性双侧瘫治疗方法进行改进,探索提高其治疗效果的方法.[方法]23例重症脑瘫痉挛性双侧瘫.男14例,女9例;年龄3～12岁,平均5.7岁;主要症状不能独自站立和行走,双下肢肌紧张,家长扶持站立,双下肢呈剪刀步态,双髋、膝关节屈曲,踝关节跖屈,双足马蹄内翻畸形,足尖着地行走.体格检查双髂腰肌、内收肌、腘绳肌、小腿三头肌、胫前肌、胫后肌、(足母)长屈肌、趾长屈肌部分或多数不同程度肌张力增高.依Ashworth分级,为3～4级.治疗方法对动态性肌痉挛,采用肌内肌腱切断或肌筋膜切断;对静态性肌痉挛行肌腱滑动延长,胫前肌腱劈开外侧1/2移位.然后用自制外固定器矫形固定,保持膝关节伸直,双踝、足中立位,双下肢外展30°,6周后去除外固定康复训练.[结果]本组病例随访1～3年,平均2.2年.优良21例,有效2例.[结论]严重脑瘫痉挛性双侧瘫,一期多关节软组织松解,肌力平衡,外固定矫形,术后配合家庭长期康复训练,是一种有效的治疗方法.     

内侧腘绳肌延长术对双侧痉挛性脑瘫下肢肌肉长度的影响

目的 观察内侧胭绳肌延长术对双测痉挛性脑瘫下肢肌肉长度的影响.方法 将双测痉挛性脑瘫患者分为两组,一组为髂腰肌组5例(10侧肢体),即内侧胭绳肌延长,股直肌远端转位加髂腰肌延长术.另一组为非髂腰肌组5例(10侧肢体),即内侧胭绳肌延长,股直肌远端转位术.利用计算机模拟骨肌肉步态模型技术,选择性计算术后下肢相关肌肉的肌肉长度,并对比分析.结果 髂腰肌组中患者的股二头肌长头肌肉长度,在步态周期中的平均值、最小值和总长度分别为0.5000±0.0080、0.4800±0.0059、50.8600±0.8084,明显长于非髂腰肌组患者(P＜0.05).股二头肌短头肌肉长度最小值在步态周期中所出现的时间(81.6700±4.3221)%GC,较非髂腰肌组患者(75.1300±1.8851)%GC明显延迟(P＜0.01),半腱肌和半膜肌肌肉长度最小值在步态周期中出现的时间分别为(72.6700±3.0768)%Gc和(73.0000±3.6332)%GC,较非髂腰肌组出现的时间(68.500±1.5119)%Gc和(68.1300±1.5526)%Gc明显延迟(P＜0.05).结论 屈髋肌挛缩组患者在施行内侧胭绳肌延长、股直肌远端转位和髂腰肌延长术后,出现胭绳肌功能不全模型的原因,是由于外侧腘肌肌肉长度较长和内侧腘绳肌肌肉长度相对较长.     

Changes in gait patterns after operations in children with spastic cerebral palsy

Summary We have utilised a scoring system with the aid of a specially designed worksheet to measure gait ability in spastic children with cerebral palsy before and after corrective soft tissue operations. Postoperatively, there were obvious improvements in gait especially in the mobility of the leg and the foot. Comparison between a visually assessed score and objectively recorded values using foot-switches showed a good correlation. The postoperative improvement was most obvious in hemiplegic children, but was also present in diplegic children following both single and complex one-stage operations.

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Résumé Afin de mesurer les possibilités de marche chez les enfants spastiques atteints de paralysie cérébrale, nous avons utilisé une cotation obtenue grâce à une abaque spécialement réalisée pour cette investigation. Les mesures ont été faites avant et après les opérations correctrices portant sur les parties molles.En post-opératoire on a noté une amélioration indiscutable de la marche, notamment en ce qui concernait la mobilité de la jambe et du pied. La comparaison entre l'estimation visuelle et les enregistrements objectifs a montré une bonne corrélation. L'amélioration post-opératoire est plus marquée chez les enfants hémiplégiques, mais elle existe aussi chez les enfants diplégiques, tant après des interventions simples que complexes.

     

Investigation of the effect of sensorimotor exercises on proprioceptive perceptions among children with spastic hemiplegic cerebral palsy

Study DesignThis is a blinded randomized clinical trial.IntroductionSensorimotor exercises may be an effective, noninvasive treatment modality for treating patients with pediatric spastic hemiplegic cerebral palsy (CP).Purpose of the StudyWe aim to evaluate the effect of sensorimotor exercises on the proprioceptive capability among children with spastic hemiplegic CP.MethodsThis randomized clinical trial was performed on children with spastic hemiplegic CP. Thirty children aged 8 to 12 years old, with spastic hemiplegic CP, were randomly selected and equally divided into experimental and control groups (N = 15 for each). A joint positioning test was used to measure the patients' baseline proprioceptive ability. The exercise program included sensory and motor exercises which lasted for 8 weeks (three 60-min sessions per week). The data were analyzed by using Welch and paired-sample t-test at the significance level of P < .05.ResultsThe results indicated that the proprioceptive capability of the upper limb could significantly improve (P = .001, effect size = 0.41, observed power = 0.99) by using simultaneous exercising of the sensorimotor complex. The mean increased from 8.53 ± 1.6 to 10.53 ± 1.19 in the experimental group, whereas it changed from 6.66 ± 3.44 to 6.73 ± 3.15 in the control group.DiscussionIn consistent with other studies, the exercises used in the present study enhanced the proprioceptive capability but not sensory performance of the hands of children with hemiplegic. Synchronous sensory and motor training in children with hemiplegic CP may improve the function and organization of the somatosensory cortex and reduce sensory disturbances. Although parents were subjectively satisfied with the outcome of the exercises, such as independency and life style, however these recordings were not measured in this study.ConclusionImplementing simultaneous sensorimotor exercises can improve the proprioceptive capability of the hand. Therefore, these exercises can be used in the rehabilitation programs to meet the children's needs with hemiplegic CP.     

关节外距下关节固定术治疗痉挛性双瘫扁平足临床疗效分析

目的：介绍应用关节外距下关节固定术治疗痉挛性双肢瘫患儿扁平外翻足畸形的手术指征和方法,对临床疗效及结果作出评价,并讨论其矫正机制和矫形效果。方法2011年4月至2013年6月我科采用关节外距下关节固定术技术治疗痉挛性双肢瘫患儿28例（46足）,并根据畸形的程度给予相应的软组织重建手术。术后根据美国足踝外科协会（American Orthopaedic Foot and Ankle Society, AOFAS）踝-后足功能评分,从疼痛、功能、对线三方面评价患儿临床效果,同时观察患儿足外翻的影像学指数的改变,比较前后位片距骨-第一跖骨角和距跟角,正侧位距骨-第一跖骨角（Meary角）、跟骨倾斜角和跟骨-第一跖骨角（Hibbs’角）的变化。结果所有患儿术后平均随访2年8个月,所有患儿骨性愈合并且畸形没有复发。采用AOFAS踝-后足功能评分标准评价临床结果,平均得分88分,28足优,18足良。影像学评价测定术前及术后随访时足负重前后位的距跟角、正侧位Meary角及Hibbs’角比较,差异均有统计学意义（均P<0.05）。结论关节外距下关节固定术治疗痉挛性双肢瘫患儿扁平外翻足畸形疗效确切,后足外翻术后的指数和距下关节稳定性得到明显改善。目前本研究仅为中短期的观察,还需要长期的随访观察。     

选择性脊神经后根切断术的临床应用

目的：选择性脊神经后根切断术治疗痉挛性脑瘫的临床应用。方法：对经过SPR手术的58例患术后情况进行分析。：SPR手术对解除肌痉挛、降低异常的肌张力效果显，但术后的下肢乏力和脊柱不稳不容忽视。结论：SPR手术是治疗痉挛性脑瘫的有效方法，但应配合术后的康复训练。     

Calcaneal lengthening osteotomy in spastic planovalgus feet

Purpose of StudyPlanovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.Methods17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.ResultsImprovement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.ConclusionCalcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.     

内收短肌和股薄肌移位术治疗脑瘫剪刀步

目的探讨采用内收短肌、股薄肌移位术治疗脑瘫剪刀步的疗效.方法自2000年7月至2004年12月采用内收短肌、股薄肌移位术为基本术式治疗脑瘫剪刀步73例,男47例,女26例;年龄为5～36岁,平均12.06岁.术前肌张力采用Ashworth法评估,1级12例,2级38例,3级18例,4级5例.术中将内收短肌止点切下,与阔筋膜张肌缝合;将股薄肌止点切下,经腘窝后方移位于股骨外髁;同时完成的手术还有髋松解术55例,腓肠肌内外侧头松解术23例,腘绳肌前移术37例,腘绳肌延长术13例,腓肠肌切断术32例,跟腱延长术30例,胫前肌外移术31例,腓骨长肌内移术8例.术后石膏托固定,6周后去除石膏行功能锻炼.手术疗效根据自行拟定的标准进行术后评估.结果术后随访6个月～4年5个月,平均24.4个月.所有患者剪刀步态均完全纠正.术后功能评估,优61例,良10例,可2例,优良率为97.25%.疗效欠佳的2例主要表现为膝部屈曲,服药后有所缓解.各组手术前后功能评分差异有统计学意义（P＜ 0.01）,术后D组与A组、B组差异有统计学意义（P＜0.05）.结论内收短肌、股薄肌移位术可有效纠正脑瘫患者剪刀步,术后功能满意;对下肢其他畸形应综合设计矫形方案,手术一次完成,以利于术后行步态训练;同时术后功能锻炼应与智商的提高相结合.     

Lever arm dysfunction in cerebral palsy gait

Skeletal structures act as lever arms during walking. Muscle activity and the ground reaction against gravity exert forces on the skeleton, which generate torque (moments) around joints. These lead to the sequence of movements which form normal human gait. Skeletal deformities in cerebral palsy (CP) affect the function of bones as lever arms and compromise gait. Lever arm dysfunction should be carefully considered when contemplating treatment to improve gait in children with CP.     

Rectus transfer in spastic diplegia

Objectives  

Change of function of the rectus femoris through medial transfer of its distal tendon. This procedure transforms a hip flexor and knee extensor into a hip and knee flexor. Thus the muscle acts as a hip flexor during the terminal stance phase and swing phase and as a knee flexor during the swing phase. This permits the foot to clear the ground and to improve the spastic gait.     

The effect of surface and internal electrodes on the gait of children with cerebral palsy, spastic diplegic type

The purpose of this study was to determine whether surface and internal fine-wire electromyography electrodes had an effect on gait. The subjects for the experiments were 38 children with the spastic diplegic type of cerebral palsy. The children were filmed using the high-speed cinematographic technique while they walked (a) with no electrodes (unencumbered), (b) with only surface electrodes, and (c) with internal electrodes. Single stance time, step length, cadence, and walking velocity were compared with analysis of variance and Bonferroni t tests. The results included a significant decrease in cadence (-6.3% of unencumbered walking; p less than 0.05) when comparing walking with surface electrodes with walking without any electrodes. The internal electrodes caused significant decreases from normal walking in the following parameters: step length for both the measured leg (-18.6%; p less than 0.005) and the nonmeasured leg (-18.0%; p less than 0.005), cadence (-7.9%; p less than 0.02), and walking velocity (-23.5%; p less than 0.005). Internal electrodes caused significant decreases as compared with surface electrodes in the step length for both the measured leg (15.7%; p less than 0.01) and the nonmeasured leg (15.6%; p less than 0.005) and walking velocity (19.7%; p less than 0.005). Single stance phase did not change significantly in any of the comparisons. It appears that the addition of the surface electrode apparatus does change the normal gait of a subject, causing a large decrease in cadence. The measurement of gait with internal electrodes causes further change in gait, resulting in large decreases in step length and walking velocity.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of community-prescribed ankle–foot orthoses on gait parameters in children with spastic cerebral palsy

Purpose To evaluate the efficacy of ankle foot orthoses (AFOs) prescribed in the community for children with cerebral palsy (CP). Methods Fifty-six children (32 boys and 24 girls, mean age 8.9 years, range 4–17) who were diagnosed as having CP were enrolled. They were grouped according to the type of CP, diplegic (n = 38) and hemiplegic (n = 18). Three-dimensional gait analyses while patient were barefoot and with AFOs were obtained and analyzed. Results The spatio-temporal findings were the most significantly changed as a result of AFO use. In the hemiplegic group, stride length was 11.7% (p = 0.001) longer with AFOs in both affected (10.2%) and non-affected (12.4%) legs, and cadence was reduced by 9.7%; walking speed was not affected. In the diplegic group, stride length with AFOs was 17.4% longer compared to barefoot (p < 0.001) and walking velocity improved by 17.8% (p < 0.001); cadence was unchanged. AFOs also increased ankle dorsiflexion at initial contact in both groups. In the hemiplegic group, AFOs produced an average 9.4° increase of dorsiflexion at initial contact (IC) on the affected side (p < 0.001) and 5.87° on the unaffected side (p = 0.007), and an increase of 9.9° (p < 0.001) dorsiflexion at swing, on the affected side. In the diplegic group, dorsiflexion at IC was increased by 13.4° on the right side and 7.8° on the left side (p = 0.05; p > 0.001, respectively) and an increase of 6° (p = 0.005) at swing. In the hemiplegic group of patients, knee flexion at initial contact on the affected side was reduced by 8.5° (p = 0.032) while in the diplegic group we found no influence. The number of patients that reached symmetry at initial double support tripled (from 5.6 to 16.7%) with the use of AFOs. Conclusions Our results showed that the use of AFOs improves spatio-temporal gait parameters and gait stability in children with spastic cerebral palsy. It has a lesser effect on proximal joint kinematics. Children with spastic hemiplegia display greater improvement than those with spastic diplegia.     

中西医综合治疗小儿痉挛型脑瘫的临床观察(附200例病例分析)

目的 :对 2 0 0例痉挛型脑瘫病例进行分析。方法 :用中西医综合性治疗并辅以功能训练。结果 :总有效率 97%,其中显效为 5 4%。结论 :本研究工作采用的治疗方法 ,对痉挛型脑瘫具有较好的效果。     

Sagittal gait patterns in spastic diplegia

Classifications of gait patterns in spastic diplegia have been either qualitative, based on clinical recognition, or quantitative, based on cluster analysis of kinematic data. Qualitative classifications have been much more widely used but concerns have been raised about the validity of classifications, which are not based on quantitative data. We have carried out a cross-sectional study of 187 children with spastic diplegia who attended our gait laboratory and devised a simple classification of sagittal gait patterns based on a combination of pattern recognition and kinematic data. We then studied the evolution of gait patterns in a longitudinal study of 34 children who were followed for more than one year and demonstrated the reliability of our classification.     

Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

Purpose To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Methods Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Results Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. Conclusion These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor. No financial support was received for this study.     

Dorsal rhizotomy in cerebral palsy: How root sectioning is influenced by intraoperative neuromonitoring?

Introduction and objectiveDorsal rhizotomy is a controversial procedure for treating spasticity in children with cerebral palsy, particularly regarding the influence of intraoperative neuromonitoring (ION). The objective of this study was to evaluate the influence of ION in adjusting root sectioning compared the preoperative program established by the multidisciplinary team.Material and methodsTwenty-four consecutive children with spastic diplegia or quadriplegia, operated on between 2017 and 2020 in the University Hospital of Nancy, France, were studied. All underwent the same procedure: Keyhole Intralaminar Dorsal rhizotomy (KIDr) with enlarged multilevel interlaminar openings to access all roots from L2 to S2. The Ventral Root (VR) was stimulated to map radicular myotomes, and the Dorsal Root (DR) to test excitability of the segmental circuitry. Muscle responses were observed independently by the physiotherapist and by EMG-recordings. The study compared final root sectioning per radicular level and per side after ION versus the preoperative program determined by the multidisciplinary team.ResultsION resulted in significant differences in final percentage root sectioning (P < 0.05), with a decrease for L2 and L3 and an increase for L5. ION modified the symmetry of sectioning, with 32% instead of 5% in preoperative program. Only 5 children showed change in GMFC score 6 months after surgery.ConclusionThe use of ION during dorsal rhizotomy led to important modifications of root sectioning during surgery, which justifies individual control of each root, level by level and side by side, to optimize the therapeutic effect.     

Local and distant effects of isolated calf muscle lengthening in children with cerebral palsy and equinus gait

Purpose The purpose was to assess the local and distant effects of isolated calf muscle lengthening in ambulant children with cerebral palsy. Methods The study included fifteen ambulant children with cerebral palsy (nine with diplegia and six with hemiplegia), average age 8.8 years, Gross Motor Function Classification System (GMFCS) level I and II. None of the children had previously undergone orthopaedic surgery, apart from one child who had tendo-achilles lengthening (TAL) nine years earlier. All the children underwent pre and post-operative clinical examination and three-dimensional gait analysis (gait analysis). Twenty calf muscle lengthenings were performed, ten TAL and ten gastrocnemius recessions (GR). Results Post-operative ankle kinematics showed significant improvements in all parameters. Ankle power during push-off increased, but only significantly after TAL. Only one limb (5%) was over-corrected. Four limbs (20%) were under-corrected and one of these limbs remained in mild equinus position in stance. There was one recurrent equinus (5%) during the follow-up period of three years (range: 13–55 months). Distant effects on joints and segments were more marked in diplegia than in hemiplegia. Ten of 17 kinematic parameters distant from the ankle joint improved significant post-operatively when the preoperative values were 1SD below or above the mean of the normal material. There was no significant deterioration in any of the measured parameters. Conclusion The improvement in ankle kinematics and kinetics supported the experience of other studies. The distant effects, which have previously not been evaluated in three planes, showed improvement in several kinematic parameters indicating that additional surgery in selected patients could be abandoned or delayed.