Rethlefsen Susan A, Yasmeh Siamak, Wren Tishya A L, Kay Robert M
Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
J Pediatr Orthop. 2013 Jul-Aug;33(5):501-4. doi: 10.1097/BPO.0b013e318288b3e7.
Progressive crouch gait occurs in patients with cerebral palsy with increasing age. Hamstring lengthening improves crouch in these patients, but hamstring contractures can recur over time. The purpose of this study was to determine whether revision hamstring lengthening is as effective as primary lengthening in improving crouched gait.
Retrospective review was performed for 39 patients with static encephalopathy, average age 10±4 years, who underwent hamstring lengthening. Twenty-one subjects underwent a single hamstring lengthening (HSL group), and 18 underwent repeat HSL (rHSL group). Range of motion (ROM) and kinematic measures from preoperative and postoperative gait analysis testing were compared within and between groups using t tests, χ2 tests, and multiple regression analyses as appropriate.
A total of 15/21 subjects in the HSL group (71%) improved stance knee extension by ≥10 degrees, as compared with 5/18 (28%) in the rHSL group (P=0.007). The HSL group had improved popliteal angle, static knee and hip extension ROM, and knee flexion at initial contact and in stance phase (P<0.003). No such improvements were seen in the rHSL group. Popliteal angle, knee and hip extension ROM, and knee flexion at initial contact and in stance phase had significantly greater improvement in the HSL than the rHSL group (P<0.01). These differences persisted after adjusting for preoperative minimum hip flexion in stance, the only variable that differed between groups preoperatively.
Repeat hamstring lengthening may delay progressive crouch, but does not result in long-term correction of crouch gait. Recurrent crouch may be caused by other factors such as quadriceps insufficiency, and may reflect the natural history of CP. Patients with recurrent crouch after hamstring lengthening are likely to benefit more from alternative surgical interventions to improve their knee position and function during gait.
Level IV-case series.
随着年龄增长，脑性瘫痪患者会出现进行性蹲伏步态。腘绳肌延长术可改善这些患者的蹲伏情况，但随着时间推移，腘绳肌挛缩可能会复发。本研究的目的是确定翻修性腘绳肌延长术在改善蹲伏步态方面是否与初次延长术同样有效。
对39例平均年龄为10±4岁的静态脑病患者进行回顾性研究，这些患者均接受了腘绳肌延长术。21例患者接受了单次腘绳肌延长术（HSL组），18例患者接受了重复腘绳肌延长术（rHSL组）。术前和术后步态分析测试中的活动范围（ROM）和运动学测量值，在组内和组间进行比较，根据情况使用t检验、χ2检验和多元回归分析。
HSL组共有15/21例患者（71%）站立位膝关节伸展改善≥10度，而rHSL组为5/18例（28%）（P=0.007）。HSL组的腘窝角、静态膝关节和髋关节伸展ROM以及初始接触和站立期的膝关节屈曲均有改善（P<0.003）。rHSL组未见此类改善。腘窝角、膝关节和髋关节伸展ROM以及初始接触和站立期的膝关节屈曲，HSL组比rHSL组有显著更大的改善（P<0.01）。在对术前站立位最小髋关节屈曲进行校正后，这些差异仍然存在，术前两组之间唯一不同的变量就是术前站立位最小髋关节屈曲。
重复腘绳肌延长术可能会延缓进行性蹲伏，但不能长期纠正蹲伏步态。复发性蹲伏可能由其他因素引起，如股四头肌功能不全，并且可能反映了脑性瘫痪的自然病程。腘绳肌延长术后出现复发性蹲伏的患者，可能从改善其步态中膝关节位置和功能的替代手术干预中获益更多。
IV级——病例系列。
