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Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?

View Article: PubMed Central - PubMed

ABSTRACT

Background: Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL).

Methods: This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others’ findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval.

Results: The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed.

Conclusions: To the authors’ knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

No MeSH data available.


The first surgeon realising the PHL: palpation of the tight medial hamstrings followed by percutaneous transverse cut using a scalpel blade.
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Figure 2: The first surgeon realising the PHL: palpation of the tight medial hamstrings followed by percutaneous transverse cut using a scalpel blade.

Mentions: Three independent surgeons blinded to each other’s findings participated in the study: the first surgeon with more than 19 years of experience with multilevel tenotomies in CP performs the percutaneous lengthening; the second undertakes the OHL procedure; and the third is in charge of pre-operative and post-operative PA measurements using a 1° calibrated goniometer (Fig. 1). The PHL procedure is undertaken in a standardised manner, as recently reported.11 With the patient lying supine, the hip is flexed to 90° and the knee extended under tension with the contralateral limb in extension (PA position). Palpation of the tight medial hamstring at the presumed myofascial junction, i.e. at the level between the middle and distal thirds of the posteromedial aspect of the thigh, is undertaken (Fig. 2). The scalpel blade is inserted parallel to the presumed myofascial junction. It is then turned 90° to produce one transverse cut in the fascia of both muscles consecutively. The blade is then turned back 90° and removed from the incision; the first surgeon then leaves the operating room as the third surgeon scrubs in to measure and record the PA. He then leaves the surgical field as the second surgeon scrubs in to extend the wound, while the patient is still in the supine position, and explore what has been really cut during PHL.


Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?
The first surgeon realising the PHL: palpation of the tight medial hamstrings followed by percutaneous transverse cut using a scalpel blade.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5382331&req=5

Figure 2: The first surgeon realising the PHL: palpation of the tight medial hamstrings followed by percutaneous transverse cut using a scalpel blade.
Mentions: Three independent surgeons blinded to each other’s findings participated in the study: the first surgeon with more than 19 years of experience with multilevel tenotomies in CP performs the percutaneous lengthening; the second undertakes the OHL procedure; and the third is in charge of pre-operative and post-operative PA measurements using a 1° calibrated goniometer (Fig. 1). The PHL procedure is undertaken in a standardised manner, as recently reported.11 With the patient lying supine, the hip is flexed to 90° and the knee extended under tension with the contralateral limb in extension (PA position). Palpation of the tight medial hamstring at the presumed myofascial junction, i.e. at the level between the middle and distal thirds of the posteromedial aspect of the thigh, is undertaken (Fig. 2). The scalpel blade is inserted parallel to the presumed myofascial junction. It is then turned 90° to produce one transverse cut in the fascia of both muscles consecutively. The blade is then turned back 90° and removed from the incision; the first surgeon then leaves the operating room as the third surgeon scrubs in to measure and record the PA. He then leaves the surgical field as the second surgeon scrubs in to extend the wound, while the patient is still in the supine position, and explore what has been really cut during PHL.

View Article: PubMed Central - PubMed

ABSTRACT

Background: Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL).

Methods: This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others’ findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval.

Results: The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed.

Conclusions: To the authors’ knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

No MeSH data available.