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Ki Hyuk Sung, MD
Department of Orthopaedic SurgerySeoul National University Bundang Hospital
Long term outcome of SEMLS including DHL in spastic diplegia
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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
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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.
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Purpose
• To investigate the long term outcome of
SEMLS including DHL in patients with CP
(GMFCS level I-III)
• Focus on the kinematic changes
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Material and methods
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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
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Exclusion criteria
• Concurrent neuromuscular disease
• History of gait correcting surgery
• History of dorsal rhizotomy
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Operative protocols
• Single event multilevel surgery by one surgeon
• Base on both clinical and gait analysis findings
• Standard postsurgical care including casting or
bracing
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Surgical principles of procedures
Procedure Clinical Criteria Gait Analysis Criteria
Intramuscular psoas lengthening Flexion contracture >15 degrees Decreased hip extension
Adductor tenotomy Hip abduction <20 degrees Decreased hip abduction
Distal hamstring lengthening Increased popliteal angleDecreased knee flexion at initial contact/terminal swing
Rectus femoris transfer Duncan-Ely test (+)Decreased/delayed peak knee flexion
Tendo Achilles lengtheningEquinus deformity with Silfverskiöld test (-)
Decreased dorsiflexion in stance, abnormal rocker, and foot drop in swing
Strayer procedureEquinus deformity with Silfverskiöld test (+)
Decreased dorsiflexion in stance and abnormal rocker
Femoral derotation osteotomy Increased femoral anteversionInternal foot progression withincreased hip internal rotation
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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
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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
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Results
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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 examination Left Right
Popliteal angle (˚) 54.4±20.7 54.3±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) 17 14
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Summary of surgical procedures
Surgical proceduresNo. at 1st operation
No. at 2nd operation
No. at 3rd operation
Total No.
Femoral derotation osteotomy
30 2 0 32
Distal hamstring lengthening 58 15 0 73
Adductor tenotomy 12 6 0 18
Rectus femoris transfer 29 11 0 40
Intramuscular psoas lengthening
12 2 0 14
TAL, Strayer or Vulpius 46 6 2 54
Calcaneal lengthening 16 2 1 19
TDO or TRO 2 4 0 6
Others* 8 1 2 11
Total 213(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.
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Temporal parameters after SEMLS
PreoperativePostoperative
(1 years)Postoperative
(10 years)
p-value
RM-ANOVA
Preop-1Y Preop-10Y 1Y-10Y
Stride length (cm)
78.9 (23.4) 87.8 (16.5) 103.0 (15.0) <0.001* 0.010 <0.001 <0.001
Cadence (steps/min)
105.9 (22.0) 99.1 (16.6) 100.2 (17.9) 0.136 0.136 0.582 1.000
Walking Speed (cm/s)
71.1 (25.4) 72.3 (17.4) 87.0 (23.1) 0.002* 1.000 0.019 0.001
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Pelvis and hip Kinematic parameters
PreoperativePostoperative
(1 years)Postoperative
(10 years)
p-value
RM-ANOVA
Preop-1Y Preop-10Y 1Y-10Y
Mean pelvic tilt (˚)
17.8 (7.9) 18.6 (6.8) 16.8 (6.3) 0.393 1.000 1.000 0.344
Minimum hip flexion (˚)
-0.9 (9.4) -2.5 (9.7) 1.8 (8.1) 0.114 1.000 0.544 0.147
Mean hip adduction (˚)
-1.7 (6.1) -1.8 (4.3) -0.1 (4.1) 0.248 1.000 0.500 0.104
Mean hip rotation (˚)
10.1 (19.1) 4.4 (13.6) -1.0 (7.7) 0.012* 0.484 0.010 0.239
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Knee kinematic parameters
PreoperativePostoperative
(1 years)Postoperative
(10 years)
p-value
RM-ANOVA
Preop-1Y Preop-10Y 1Y-10Y
Knee flexion at initial contact (˚)
31.1 (12.7) 26.0 (7.6) 23.6 (8.1) 0.011* 0.065 0.038 0.400
Minimum knee flexion in stance (˚)
7.6 (13.8) 2.7 (9.8) 7.3 (10.6) 0.114 0.110 1.000 0.187
Peak knee flexion in swing (˚)
55.3 (15.8) 57.6 (10.1) 57.4 (7.6) 0.621 1.000 1.000 1.000
Knee range of motion (˚)
47.7 (14.3) 54.9 (13.0) 50.2 (12.0) 0.067 0.078 1.000 0.432
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Ankle and foot kinematic parameters
PreoperativePostoperative
(1 years)Postoperative
(10 years)
p-value
RM-ANOVA
Preop-1Y Preop-10Y 1Y-10Y
Ankle dorsiflexion at initial contact (˚)
1.8 (10.0) 7.1 (10.8) 1.2 (6.4) 0.007* 0.059 1.000 0.011
Peak ankle dorsiflexion in stance (˚)
16.7 (14.1) 18.6 (11.9) 14.7 (7.2) 0.282 1.000 1.000 0.228
Peak ankle dorsiflexion in swing (˚)
9.8 (17.2) 14.5 (14.0) 7.1 (6.6) 0.05* 0.469 1.000 0.017
Mean foot progression in stance (˚)
0.2 (18.9) -8.9 (11.0) -9.7 (9.9) 0.001* 0.011 0.007 1.000
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GDI after SEMLS
PreoperativePostoperative
(1 years)Postoperative
(10 years)
p-value
RM-ANOVA
Preop-1Y Preop-10Y 1Y-10Y
69.4 (11.3) 77.9 (9.5) 82.2 (8.9) <0.001* 0.003 <0.001 0.017
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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
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