Long term outcome of SEMLS
including DHL in spastic diplegia
Ki Hyuk Sung, MD
Department of Orthopaedic Surgery
Seoul National University Bundang Hospital
Introduction
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
• 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
Introduction
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
• 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.
Purpose
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
• To investigate the long term outcome of SEMLS
including DHL in patients with CP (GMFCS level
I-III)
• Focus on the kinematic changes
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
Inclusion criteria
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
• 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
Exclusion criteria
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
• Concurrent neuromuscular disease
• History of gait correcting surgery
• History of dorsal rhizotomy
Operative protocols
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
• Single event multilevel surgery by one surgeon
• Base on both clinical and gait analysis findings
• Standard postsurgical care including casting or bracing
Surgical principles of procedures
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
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 angle
Rectus femoris transfer
Duncan-Ely test (+)
Tendo Achilles lengthening
Equinus deformity with
Silfverskiöld test (-)
Strayer procedure
Equinus deformity with
Silfverskiöld test (+)
Femoral derotation osteotomy
Increased femoral anteversion
Decreased knee flexion at initial
contact/terminal swing
Decreased/delayed peak knee
flexion
Decreased dorsiflexion in stance,
abnormal rocker, and foot drop in
swing
Decreased dorsiflexion in stance
and abnormal rocker
Internal foot progression with
increased hip internal rotation
Acquisition of data
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
• 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
GDI (gait deviation index)
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
• 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
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
Dermographics and preop P/Ex
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
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)
Preoperative physical examination
7/19/3
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
17
14
Ely test (positive)
Summary of surgical procedures
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
No. 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
213(7.3)
49(1.7)
5(0.2)
267 (9.1)
Surgical procedures
Total
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.
Temporal parameters after SEMLS
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
Stride length
(cm)
Cadence
(steps/min)
Walking Speed
(cm/s)
p-value
Preoperative
Postoperative
(1 years)
Postoperative
(10 years)
78.9 (23.4)
87.8 (16.5)
103.0 (15.0)
<0.001*
0.010
<0.001
<0.001
105.9 (22.0)
99.1 (16.6)
100.2 (17.9)
0.136
0.136
0.582
1.000
71.1 (25.4)
72.3 (17.4)
87.0 (23.1)
0.002*
1.000
0.019
0.001
RMANOVA
Preop-1Y Preop-10Y 1Y-10Y
Pelvis and hip Kinematic parameters
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
Mean pelvic
tilt (˚)
Minimum hip
flexion (˚)
Mean hip
adduction (˚)
Mean hip
rotation (˚)
p-value
Preoperative
Postoperative
(1 years)
Postoperative
(10 years)
17.8 (7.9)
18.6 (6.8)
16.8 (6.3)
0.393
1.000
1.000
0.344
-0.9 (9.4)
-2.5 (9.7)
1.8 (8.1)
0.114
1.000
0.544
0.147
-1.7 (6.1)
-1.8 (4.3)
-0.1 (4.1)
0.248
1.000
0.500
0.104
10.1 (19.1)
4.4 (13.6)
-1.0 (7.7)
0.012*
0.484
0.010
0.239
RMANOVA
Preop-1Y Preop-10Y 1Y-10Y
Knee kinematic parameters
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 flexion at
initial contact (˚)
Minimum knee
flexion in stance (˚)
Peak knee flexion in
swing (˚)
Knee range of
motion (˚)
Preoperative
Postoperative
(1 years)
Postoperative
(10 years)
31.1 (12.7)
26.0 (7.6)
7.6 (13.8)
p-value
RMANOVA
Preop-1Y
Preop-10Y
1Y-10Y
23.6 (8.1)
0.011*
0.065
0.038
0.400
2.7 (9.8)
7.3 (10.6)
0.114
0.110
1.000
0.187
55.3 (15.8)
57.6 (10.1)
57.4 (7.6)
0.621
1.000
1.000
1.000
47.7 (14.3)
54.9 (13.0)
50.2 (12.0)
0.067
0.078
1.000
0.432
Ankle and foot kinematic parameters
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 dorsiflexion at
initial contact (˚)
Peak ankle dorsiflexion
in stance (˚)
Peak ankle dorsiflexion
in swing (˚)
Mean foot progression
in stance (˚)
Preoperative
Postoperative
(1 years)
Postoperative
(10 years)
1.8 (10.0)
7.1 (10.8)
16.7 (14.1)
p-value
RMANOVA
Preop-1Y
Preop-10Y
1Y-10Y
1.2 (6.4)
0.007*
0.059
1.000
0.011
18.6 (11.9)
14.7 (7.2)
0.282
1.000
1.000
0.228
9.8 (17.2)
14.5 (14.0)
7.1 (6.6)
0.05*
0.469
1.000
0.017
0.2 (18.9)
-8.9 (11.0)
-9.7 (9.9)
0.001*
0.011
0.007
1.000
GDI after SEMLS
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
Preoperative
Postoperative
(1 years)
Postoperative
(10 years)
69.4 (11.3)
77.9 (9.5)
82.2 (8.9)
p-value
RMANOVA
Preop-1Y
Preop-10Y
1Y-10Y
<0.001*
0.003
<0.001
0.017
Conclusion
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
• 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
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