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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.


Related in: MedlinePlus

Semitendinosus (a) and semimembranous (b) muscles sectioned by PHL. Significant damage to muscular portion is noted.
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Figure 3: Semitendinosus (a) and semimembranous (b) muscles sectioned by PHL. Significant damage to muscular portion is noted.

Mentions: He reports the extent of fascial and muscular fibres cut into four categories: complete cut; more than 75% cut; between 50% and 75%; and less than 50% (Fig. 3). He looks for iatrogenic injury to the popliteal vessels, sciatic nerve and to neighbouring muscles, mainly the sartorius. He then completes the medial hamstring fractional lengthening when necessary and invites the third surgeon to come back and measure the PA following OHL, and proceeds with other planned releases.


Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?
Semitendinosus (a) and semimembranous (b) muscles sectioned by PHL. Significant damage to muscular portion is noted.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: Semitendinosus (a) and semimembranous (b) muscles sectioned by PHL. Significant damage to muscular portion is noted.
Mentions: He reports the extent of fascial and muscular fibres cut into four categories: complete cut; more than 75% cut; between 50% and 75%; and less than 50% (Fig. 3). He looks for iatrogenic injury to the popliteal vessels, sciatic nerve and to neighbouring muscles, mainly the sartorius. He then completes the medial hamstring fractional lengthening when necessary and invites the third surgeon to come back and measure the PA following OHL, and proceeds with other planned releases.

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.


Related in: MedlinePlus