francisco angulo parker, md pgy3 uky pm&r knee hyperextension after hamstring lengthening in...
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Francisco Angulo Parker, MDPGY3UKY PM&R
KNEE HYPEREXTENSION AFTER HAMSTRING LENGTHENING IN
CEREBRAL PALSY: INCIDENCE, PREDICTIVE FACTORS AND
COST IN GAIT EFFICIENCY
CEREBRAL PALSY
Cerebral palsy (CP) is the leading cause of childhood disability aff ecting function & development
Overall estimated prevalence of CP is 2-2.5 cases per 1000 live births
Criteria for CP: Static Brain lesion Neuro-motor control deficit that affects movement or
posture Immature brain
HAMSTRING LENGTHENING
Goal of surgery in ambulatory patients
To improve gait
effi ciency
To improve knee
flexion deformity
To increase knee
extension at the end of
swing phase and at
heel strike
Crouching gait
DESCRIPTIVE STATISTICS
No. (%)
Gender
Male 97 (66%)
Female 50 (34%)
GMFCS 1 26 (17.7%)
GMFCS 2 48 (32.7%)
GMFCS 3 73 (49.7%)
Mean(std)
Age at surgery 12. 1 (3.2) years
Duration b/w surgery & post op gait analysis
1.4 (1.1) years
KINEMATICS IN GAIT EFFICIENCYPOOR DATA PREDICTING KNEE HYPEREXTENSIONREGARDED AS POOR OUTCOMEAVAILABILITY OF DATABASESERIES OF STUDIES FROM SAME DATABASE
BACKGROUND
Incidence
Can we predict it? What are the predictive variables?
Cost of knee hyperextension in gait effi ciency
OBJECTIVES
Retrospective, case control study.
Regression analysis for predicting variables.
METHODOLOGY
POPULATION
Diagnosis Frequency
CP hemiplegia 2
CP diplegia 142
HSP 5
parplegia 3
fredrichs ataxia 1
Total 153
POPULATION
Characteristics
Gender 93 males 49 female
Previous Hamstring No: 110 Yes: 32
POPULATION
Procedures
33 only HS lengthening34 TAL and HS lengthening30 Rectus transfer and HS lengthening27 TAL, HS lengthening and rectus transfer
POPULATION
284 knees (142 patients)
Hyperextension considered 0 deg and above pass full extension
11.5% of the knees showed hyperextension post HS lengthening
INCIDENCE OF KNEE HYPEREXTENSION
Preop GMFCSLevel Age at surgery Other simultaneous surgery (yes/no) Simultaneous RECTUS (yes/no) Preop L Popliteal angle Preop L Knee extension Preop L Knee fl exor tone Preop L hip extensor Preop L knee Flexor Preop L knee Extensor PRE L 0 = knee fl exion at initial contact preop PRE L 30 = knee fl exion at mid-stance preop Change HT change in height from preop to post op Change WT change in weight from preop to post op
VARIABLE ANALYSIS FOR PREDICTION
Variables in the Equation
B S.E. Wald df Sig. Exp(B)
Step 1a
preGMFCSLevel 1.027 .424 5.854 1 .016 2.793
age_atsurgery -.131 .087 2.262 1 .133 .877
othersimultaneoussurgery -.253 .199 1.620 1 .203 .776
simultaneous_RECTUS .316 .614 .266 1 .606 1.372
Preop__Popliteal_angle .057 .027 4.533 1 .033 1.059
Preop__Knee_extension .013 .039 .114 1 .736 1.013
Pre_op__Knee_flexor_tone .382 .273 1.966 1 .161 1.466
Pre_op__hip_extesor_contr
ol.310 .196 2.516 1 .113 1.364
Pre_op__knee_Flexor_cont
rol.024 .241 .010 1 .921 1.024
Pre_op__knee_Extensor_c
ontrol-.476 .345 1.906 1 .167 .622
PRE__0 -.049 .027 3.225 1 .073 .953
PRE__30 -.046 .023 4.070 1 .044 .955
changeHT .009 .040 .053 1 .818 1.009
changeWT .034 .037 .861 1 .354 1.035
timetofollowup -.060 .164 .134 1 .715 .942
Constant -1.339 3.043 .194 1 .660 .262
VARIABLES
Statistically significant P=<0.05 Pre GMFCS Pre op angle Pre operative knee flexion at midstance
Clinically significant Significant results only present in Pre operative knee
flexion at midstance
VARIABLE ANALYSIS FOR PREDICTION
GAIT
Stance phase (1) Limb of interest in contact
with ground 60% of gait when walking
Heel strike loading response - foot plantar
flexes to ground midstance - tibia shifts
forward over plantigrade foot terminal stance – heel rise preswing
Swing phase (1) Limb of interest in air 40% of gait when walking
Initial swing – begins with toe off , limb moves forward
Midswing – when limb passes grounded limb
Terminal swing – also known as deceleration, slow down towards heel strike
Pre-operative knee flexion at midstance
Not hyperextended. Mean: 35.451 SD: 16.2
Hyperextended Mean: 23.9 SD: 17.59
RESULTS
Measured by Oxygen consumption pre and post bilateral hamstring lengthening
Same database
Only 78 subjects with preop and post op oxygen consumption data
GAIT EFFICIENCY
Oxygen consumption
Amount of oxygen consumed per kg of body weight over time (mL/kg-min)
Total power required to keep the body in motion
Related to the level of effort it takes to walk Does not take walking velocity into account
GAIT EFFICIENCY
Group Statistics
post_Hyper_R N Mean Std. Deviation Std. Error Mean
PreO2ConsumptionExercisenot hyper 69 18.938 3.8794 .4670
hyper 9 19.422 3.2468 1.0823
Pre02Costnot hyper 69 .6293 .30379 .03657
hyper 9 .7344 .24895 .08298
PostO2ConsumptionExercisenot hyper 69 17.233 3.4472 .4150
hyper 9 17.722 4.1176 1.3725
Post02Costnot hyper 69 .5419 .19304 .02324
hyper 9 .6233 .20062 .06687
Change_O2_costnot hyper 69 -.0874 .21070 .02536
hyper 9 -.1111 .12830 .04277
Change_O2_Consumnot hyper 69 -1.7043 3.97937 .47906
hyper 9 -1.7000 2.73359 .91120
RESULTS
Incidence of knee hyperextension after hamstring lengthening in our population is 11.5%
Significant variable: knee flexion at midstance
Statistical and clinical significance at a mean of 23.9 degrees when compared to a mean of 35.4 degrees
No significant change in Oxygen consumption in hyperextended vs non-hyperextended knees
CONCLUSION
Clinical follow up at 1.5 years after surgery. Long term observance should be considered
Insufficient knee flexion at midstance would bring up the incidence to approximately 25%
What is the efficiency cost in chronic knee hyperextension?
Overall, the prediction of hyperextension continues to be difficult
DISCUSSION
1. H e r r i n g JA , Ta c h d j i a n M O. Tex a s S c o t t i s h R i t e H o s p i t a l f o r C h i l d re n . Ta c h d j i a n ’ s Pe d i a t r i c O r t h o p a e d i c s . 4 t h E d i t i o n . P h i l a d e l p h i a : S a u n d e r s / E l s e v i e r ; 2 0 0 8
2. Ro s e n b a u m P , Pa n e t h N , Le v i t o n A , e t a l . A re p o r t : t h e d e fi n i t i o n a n d c l a s s i fi c a t i o n o f c e re b r a l p a l s y. D e v M e d C h i l d N e u ro l S u p p l . 2 0 0 7 ; 1 0 9 : 8 – 1 4 .
3. G o rd o n A B , B a i rd G O , M c M u l k i n M L , C a s ke y P M , Fe rg u s o n R L . G a i t a n a l y s i s o u t c o m e s o f p e rc u t a n e o u s m e d i a l h a m s t r i n g t e n o t o m i e s i n c h i l d re n w i t h c e re b r a l p a l s y. J o u rn a l o f Pe d i a t r i c O r t h o p a e d i c s 2 0 0 8 ; 2 8 ( 3 ) : 3 2 4 – 9 .
4. U n n i t h a n V B , D o w l i n g J J , Fro s t G , B a r- O r O. ( 1 9 9 9 ) Ro l e o f m e c h a n i c a l p o w e r e s t i m a t e s i n t h e O 2 c o s t o f w a l k i n g i n c h i l d re n w i t h c e re b r a l p a l s y. M e d S c i S p o r t s E x e r 3 1 : 1 7 0 3 – 1 7 0 8 .
5. C a n a l e S T , B e a t y J H . C a m p b e l l ’ s O p e r a t i v e O r t h o p a e d i c s . 1 1 t h E d i t i o n . Ac c e s s e d O n l i n e . 6. D h a w l i ka r S H, Ro o t L, M a n n R L. D i s t a l l e n g t h e n i n g o f t h e h a m s t r i n g s i n p a t i e n t s w h o h a v e c e re b r a l
p a l s y. Lo n g - t e rm re t ro s p e c t i v e a n a l y s i s . J B o n e J o i n t S u rg A m . 1 9 9 2 O c t ; 7 4 ( 9 ) : 1 3 8 5 - 9 1 .7. S . L . D e l p , A . S . A rn o l d , R . A . S p e e r s , a n d C . A . M o o re , " H a m s t r i n g s a n d p s o a s l e n g t h s d u r i n g n o rm a l
a n d c ro u c h g a i t : i m p l i c a t i o n s f o r m u s c l e - t e n d o n s u rg e r y , " J o u r n a l o f O r t h o p a e d i c R e s e a r c h , v o l . 1 4 , p p . 1 4 4 - 1 5 1 , 1 9 9 6 .
8. D e Lu c a P , O u n p u u O , D a v i s R B , Wa l s h J : E ff e c t o f h a m s t r i n g s a n d p s o a s l e n g t h e n i n g o n p e l v i c t i l t i n p a t i e n t s w i t h s p a s t i c d i p l e g i c c e re b r a l p a l s y. J o u r n a l o f P e d i a t r i c O r t h o p a e d i c s 1 9 9 8 , 1 8 : 7 1 2 - 7 1 8 .
9. G a g e J R , N o v a c h e c k T F. ( 2 0 0 1 ) A n u p d a t e o n t h e t re a t m e n t o f g a i t p ro b l e m s i n c e re b r a l p a l s y. J P e d i a t r O r t h o p B 1 0 : 2 6 5 – 2 7 4 .
10. B . T. C a rn e y , D . O e ffi n g e r a n d A . M . M e o , S a g i t t a l k n e e k i n e m a t i c s a f t e r h a m s t r i n g l e n g t h e n i n g , J P e d i a t r O r t h o p B 15 ( 5 ) ( 2 0 0 6 ) , p p . 3 4 8 – 3 5 0 .
11. J . R . G a g e a n d T. F. N o v a c h e c k , A n u p d a t e o n t h e t re a t m e n t o f g a i t p ro b l e m s i n c e re b r a l Pa l s y , J P e d i a t r O r t h o p 10 ( Pa r t B ) ( 2 0 0 1 ) , p p . 2 6 5 – 2 7 4
12. Pa l i s a n o R , Ro s e n b a u m P , Wa l t e r S , Ru s s e l l D , Wo o d E , G a l a p p i B . ( 1 9 9 7 ) D e v e l o p m e n t a n d re l i a b i l i t y o f a s y s t e m t o c l a s s i f y g ro s s m o t o r f u n c t i o n i n c h i l d re n w i t h c e re b r a l p a l s y. D e v M e d C h i l d N e u r o l 3 9 : 2 1 4 –2 2 3 .
13. C h a n g W N , Ts i r i ko s A I , M i l l e r F M , Le n n o n N , S c h u y l e r J , Ke r s t e t t e r L , G l u t t i n g J , . D i s t a l H a m s t r i n g Le n g t h e n i n g i n a m b u l a t o r y c h i l d re n w i t h C e re b r a l p a l s y: p r i m a r y v e r s u s re v i s i o n p ro c e d u re s . G a i t a n d Po s t u re . ( 2 0 0 4 ) 1 9 : 2 9 8 - 3 0 4
14. S c h w a r t z M H , V i e h w e g e r E , S t o u t J , N o v a c h e c k T F , G a g e J R . C o m p re h e n s i v e t re a t m e n t o f a m b u l a t o r y c h i l d re n w i t h c e re b r a l p a l s y: a n o u t c o m e a s s e s s m e n t . J o u rn a l o f Pe d i a t r i c O r t h o p e d i c s 2 0 0 4 ; 2 4 : 4 5 – 5 3 .
REFERENCES
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