Experts address hamstring, guided growth surgery in children with cerebral palsy
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An international group of experts published guidelines on hamstring lengthening surgery and anterior distal femoral hemiepiphysiodesis to guide surgeons in their care of ambulatory children with cerebral palsy.
“We recognize that doing good research gives surgeons information about how individual centers approach [treatment of patients with cerebral palsy], but we thought it would be important to have a group of international experts come to some consensus so that there would be actionable items that surgeons could use to approach the treatment and enhance the care of these children,” Robert Kay, MD, division chief of orthopedic surgery at Children’s Hospital Los Angeles, told Healio.
Published in the Journal of Children’s Orthopaedics, the guidelines on hamstring lengthening surgery and anterior distal femoral hemiepiphysiodesis — also known as guided growth surgery — in ambulatory children with cerebral palsy were established by a group of 16 expert surgeons from 15 centers across North America, Europe and Australia.
“We felt that these guidelines incorporate not only a lot of expert opinion, but a lot of expert opinion across various demographics and different patient types and patient patterns,” Kay, who was the lead author on the hamstring lengthening guidelines and a senior author on the guided growth guidelines, said. “It allows us to give broader recommendations that we think will apply to more patients than if we did one study looking at hamstring lengthening from one institution with a few surgeons.”
Hamstring lengthening
In the guidelines for hamstring lengthening, Kay said it is important for surgeons to perform a computerized gait analysis to provide objective information on whether the patient is a good candidate for the surgery.
“We can look at how someone walks. We can feel how tight their muscles are, but in the gait analysis, they can generate this data that accurately shows if their hamstrings are too long or too short,” Kay said. “If they are too short on the hamstring modeling data, that is the best indicator that they can benefit from a hamstring lengthening surgery.”
Hamstring lengthening also works best in children with no or mild knee flexion contracture of less than 10°, according to Kay. He added the panel agreed that repeat hamstring lengthening often leads to inferior results.
“The results of doing a primary hamstring lengthening, the first time a patient has that done, those are often successful, but doing a revision or a repeat hamstring lengthening, those results are far inferior,” Kay said. “So, you have to think twice before you consider a repeat hamstring lengthening.”
Kay said the panel also agreed that surgeons should “almost always exclusively” perform a medial hamstring lengthening and almost never perform a lateral hamstring lengthening.
, and there are some previous studies, including one that we had published at our institution, which showed that if you do the lateral hamstring lengthenings, there is a higher rate of overcorrection, so the knee can hyperextend after surgery.”
Guided growth surgery
A good procedure for adolescent patients, guided growth surgery is “a way to address knee flexion contracture that is not responsive enough to a hamstring lengthening,” Kay said.
“Guided growth allows us to help straighten the knees in patients who still have remaining growth, but it is less invasive,” he said. “If the only procedure you are doing is the guided growth at the knees, the patients can resume their normal activity on the day of surgery without any restrictions.”
Although patients with knee flexion contractures of 10° to 20° are the ones who benefit the most from guided growth surgery, Kay noted sometimes patients with larger contractures may also be able to benefit from this procedure. He added performing guided growth with a screw-only construct is preferable in children with cerebral palsy compared with a plate and screw construct.
“With the plates and screws, there is a lot more pain. And so we can avoid that excessive pain by doing just the screws only,” Kay said.
Consider the whole patient
Whether performing a hamstring lengthening or guided growth surgery, Kay said it is important that the surgeon considers the child as a whole and identify any additional areas that may need to be addressed.
“These procedures need to be considered in the overall approach of a single event, multilevel surgery where you address all of the multiple levels of involvement simultaneously to give patients the best outcome,” he said. “That entails both a regular exam, as well as a computerized gait analysis, so that you can optimize your precision of your decision-making and minimize the risk of needing to do additional surgeries for those children.”
Kay said he hopes the publication of these guidelines provides “a consistent framework from which surgeons throughout the world, whether they have much experience or not in the treatment of these children, can improve their patient care, improve their decision- making and become more consistent in how they treat these children.”
“It has been shown repeatedly throughout medicine, whether it’s orthopedics or other fields of medicine, that if you can become more consistent in your care of people with a given condition that you will, overall, decrease variability and improve the outcomes in that patient population,” Kay said.
References:
Kay RM, et al. J Child Orthop. 2022;doi:10.1177/18632521221080474.
New guidelines for hamstring lengthening and guided growth surgery. https://www.newswise.com/articles/new-guidelines-for-hamstring-lengthening-and-guide-growth-surgery. Published Oct. 14, 2022. Accessed Nov. 18, 2022.
Shore BJ, et al. J Child Orthop. 2022;doi:10.1177/18632521221087529.
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