SCIENTIFIC ARTICLE
Early Results of Anterior Elbow Release With and Without Biceps Lengthening in Patients With Cerebral Palsy Hyun Sik Gong, MD, Hoyune Esther Cho, MS, Chin Youb Chung, MD, Moon Seok Park, MD, Hyuk Jin Lee, MD, Goo Hyun Baek, MD Purpose To investigate the effect of partial biceps lengthening on elbow flexion posture and active elbow flexion and extension in patients with cerebral palsy. Methods We retrospectively reviewed 29 patients with cerebral palsy who underwent anterior elbow release as part of multilevel upper extremity surgery. The early series of the patients (N ¼ 14; group 1) had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous adventitia off the biceps tendon. The later series of patients (N ¼ 15; group 2) had partial biceps tendon lengthening in addition to the procedures in group 1. We compared the 2 sets of patients for elbow flexion posture, active elbow flexion and extension, forearm rotation, and House scores, with mean follow-ups of 72 months for group 1 and 31 months for group 2. Results The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House scores. Group 2 patients had more improvement in flexion posture (53 vs 44 ) and active extension (23 vs 15 ) than group 1 postoperatively. However, group 2 had a mean decrease of 7 in active elbow flexion, whereas group 1 had no changes. There was no difference in forearm supination or in the improvement of House scores between groups. Conclusions Early results of partial lengthening of the biceps tendon showed that it may improve elbow flexion posture and active elbow extension in patients with flexion deformity in cerebral palsy. (J Hand Surg Am. 2014;39(5):902e909. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Cerebral palsy, flexion deformity, anterior elbow release, biceps lengthening. flexion deformity is caused by spasticity of the biceps, brachialis, and brachioradialis in patients with cerebral palsy (CP).1e4 Elbow flexion deformity can interfere
E
LBOW FLEXION POSTURE OR
From the Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; and the Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea. Received for publication December 6, 2013; accepted in revised form February 14, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Hyun Sik Gong, MD, Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; e-mail: hsgong@ snu.ac.kr. 0363-5023/14/3905-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.02.012
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with hand positioning for functional activities and is of aesthetic concern as the deformity becomes more pronounced during ambulation.3e5 To improve elbow flexion deformity or spasticity, several surgical treatments have been performed, such as neurectomy of the musculocutaneous nerve, release of the flexorpronator muscle from the medial epicondyle, and lengthening of the anterior elbow muscles.6 Because the musculocutaneous nerve has been cut only for mild contractures and because flexorepronator muscle release has been shown to have less of an effect at the elbow than at the hand, lengthening of the anterior elbow muscles is considered the standard surgical treatment of elbow flexion deformity.1,3,4,7 For anterior elbow release, Mital1 performed a division of the lacertus fibrosus, z-plasty of the biceps,
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
and fractional lengthening of the brachialis, and reported improvement in flexion contracture from 48 to 10 . Although Mital reported no loss of elbow flexion, he noticed weakness of supination in 1 patient, which may have resulted from lengthening of the biceps, a principal supinator of the forearm. Manske et al3 pointed out that this potential risk of supination loss is a major concern in patients with CP, who usually have a pronation deformity of the forearm. They modified the procedure of Mital: Instead of lengthening the biceps, they denuded the pretendinous adventitia off the biceps, potentially removing afferent nerve fibers and receptors. However, Carlson et al4 performed partial lengthening of the biceps (sliding without z-plasty lengthening) in patients with fixed elbow contractures less than 45 and reported greater reduction in elbow flexion posture compared with the results of Manske et al (57 improvement vs 49 ), which they attributed to partial lengthening of the biceps tendon. However, their study was a case series without an internal control group. For patients with fixed flexion contracture less than 45 , we used the procedure of Manske et al3 for anterior elbow release in our earlier patients; later, we added partial lengthening of the biceps tendon. The purpose of this study was to compare the outcomes of the 2 sets of procedures done by a single surgeon, to determine the effect of partial lengthening of the biceps tendon on elbow flexion posture and active elbow flexion and extension.
included 14 with a mean age of 21 years (SD, 12 y; range, 6e54 y) and the later patients (group 2) included 15 patients with a mean age of 20 years (SD, 5 y; range, 10e34 y). Group 1 patients were reviewed with a mean follow-up of 72 months (range, 48e96 mo) and group 2 patients were reviewed with a mean follow-up of 31 months (range, 12e54 mo). Group 1 included 9 males and 5 females, and group 2 had 11 males and 4 females. All patients had spastic hemiplegia or tetraplegia, and no patients were ataxic or dyskinetic. Surgical procedures For anterior elbow release in group 1, we made a transverse incision over the antecubital fossa, divided the lacertus fibrosus (Fig. 1), and fractionally lengthened the brachialis muscle by making 2 transverse incisions spanning the entire width of the aponeurosis over the muscle and extending the elbow (Fig. 2). We did not cut the brachialis muscle fibers. Then, we stripped the adventitia off the length of the biceps tendon to disrupt afferent nerve fibers, as described by Manske et al.3 For group 2 patients, we added partial lengthening of the biceps tendon to the procedure. We made 2 transverse incisions 3 cm apart (1 on the medial half of the tendon and the other on the lateral half), and extended the elbow to separate these 2 partial tenotomy sites (Fig. 3). We placed 2 nonabsorbable sutures between the 2 tenotomy sites to prevent further splitting of the fibers (Fig. 4).6 We did not perform z-plasty lengthening of the biceps tendon, brachioradialis release, or capsular or ligamentous release of the elbow. In addition to anterior elbow release, patients received other upper extremity procedures as singleevent multilevel upper extremity surgery. There was no change in principles and techniques throughout the study period. Tables 1 and 2 present the additional surgical procedures patients received. For forearm deformity, we performed pronator rerouting for absent or weak active supination, pronator tenotomy for active supination short of neutral, and rotational osteotomy for a fixed pronation deformity.8,9 For wrist deformity, we transferred the flexor carpi ulnaris to the extensor carpi radialis brevis for patients with wrist flexion deformity and transferred the extensor carpi ulnaris to the extensor carpi radialis brevis with fractional lengthening of the wrist flexors for patients with primarily wrist ulnar deviation deformity.10 We performed wrist arthrodesis in patients with fixed flexion contracture of the wrist.11 For the fingers, we fractionally lengthened the digital flexor tendons for tight flexors and sometimes
MATERIALS AND METHODS Subjects We reviewed patients with CP who underwent singleevent, multilevel upper extremity surgery between May 2004 and March 2012. All procedures were done by the same hand surgeon (H.G.). Our institutional review board approved this study. A total of 31 patients underwent anterior elbow release, and 29 of them with follow-up of more than 1 year and complete data were included in this study. The indication for surgery was a preoperative flexion posture of greater than 50 with activities.3 Earlier patients (May 2004 to March 2008) had anterior elbow release procedure for elbow flexion posture, described by Manske et al3: division of the lacertus fibrosus, fractional lengthening of the brachialis, and denuding of the pretendinous adventitia of the biceps tendon. The later patients (April 2008 to March 2012) had the same procedures and added fractional lengthening of the biceps tendon.6 The earlier patients (group 1) J Hand Surg Am.
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FIGURE 1: We made a transverse incision on the elbow and divided the lacertus fibrosus (dashed line) (left elbow; the left side is proximal).
FIGURE 3: After stripping the adventitia off the biceps tendon, we made 2 transverse incisions 3 cm apart: 1 on the medial half of the tendon and the other on the lateral half.
FIGURE 2: We fractionally lengthened the brachialis muscle by making 2 transverse incisions (white arrows) spanning the entire width of the aponeurosis over the muscle, and then extending the elbow.
FIGURE 4: We extended the elbow to separate the 2 partial tenotomy sites of the biceps tendon and placed nonabsorbable sutures (black arrow) to prevent further splitting of the fibers.
a long-arm cast for 4 weeks after tendon transfer surgery and for 6 weeks after arthrodesis or osteotomy, and then patients started physiotherapy. We did not employ long-term splinting of the elbow.
performed flexor digitorum superficialis to flexor digitorum profundus transfer for patients who were not able to passively extend the fingers with the wrist in flexion.12 For thumb-in-palm deformity, we performed z-plasty lengthening of the first web, proximal advancement of the adductor pollicis insertion, and rerouting of the extensor pollicis longus.10 We also performed fractional lengthening of the flexor pollicis longus in patients with flexed thumb interphalangeal joint and volar capsulodesis for hyperextension of the metacarpophalangeal joint.12 For severe swan-neck deformities, we usually performed central tendon tenotomy or sometimes lateral band rerouting in patients with severe laxity of the volar plate.13 Postoperatively, we immobilized patients with J Hand Surg Am.
Outcome evaluation and analyses A research assistant (orthopedic research nurse) measured elbow flexion posture, active elbow flexion and extension, and elbow flexion contracture preoperatively and at each postoperative visit. The examiner placed the goniometer axis over the lateral epicondyle, the stationary arm parallel to the longitudinal axis of the humerus pointing to the tip of the acromion, and the moving arm parallel to the longitudinal axis of the forearm pointing to the middle portion of the wrist. Elbow flexion posture was measured using r
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TABLE 1.
Procedures Performed on Group 1 Patients (Anterior Elbow Release With Denuding of Pretendinous Adventitia of Biceps)
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Age
Sex
Forearm Pronation
Wrist Flexion
Swan Neck
Finger Flexion
Thumb-in-Palm
1
12
M
2
13
M
3
20
M
PT tenotomy
4
54
M
PT tenotomy
5
13
F
ECU to ECRB
6
16
F
FCU to ECRB
7
17
M
8
22
M
ECU to ECRB
FDS FL, FDP FL
9
25
M
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
10
6
F
PT tenotomy
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis
11
20
M
PT rerouting
FCU to ECRB
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
12
21
M
FCU to ECRB, FCR FL
STP
FPL FL
13
25
F
PT rerouting
FCU to ECRB
STP
Web deepening, EPL rerouting, AP advancement, FPL z-plasty
14
35
F
PT rerouting
ECU to ECRB, FCU FL
PT rerouting FCU to ECRB
Radial and ulnar osteotomy
FCU to ECRB
FCU to ECRB, FCR FL
FDS FL, FDP FL
CT tenotomy in index and middle fingers
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
J Hand Surg Am.
Patient
Web deepening, EPL rerouting, AP advancement
PT, pronator teres; FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FL, fractional lengthening; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus; CT, central tendon; AP, adductor pollicis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; STP, superficialis transfer to profundus; ECU, extensor carpi ulnaris.
905
906
TABLE 2.
Procedures Performed on Group 2 Patients (Anterior Elbow Release With Lengthening of Biceps Tendon)
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Age
Sex
Forearm Pronation
Wrist Flexion
1
20
M
2
34
M
3
17
M
PT rerouting
FCU to ECRB
4
18
F
PT rerouting
FCU to ECRB
5
25
M
FCU to ECRB, FCR FL
6
24
M
FCU to ECRB
7
14
M
8
16
9
Swan Neck
Finger Flexion
FDS FL, FDP FL
Thumb-in-Palm
FPL FL EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
FDS FL, FDP FL
FPL FL
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
F
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
14
M
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
10
22
M
PT tenotomy
Wrist fusion
FDS FL, FDP FL
FPL FL
11
21
M
FCU to ECRB, FCR FL
STP
FPL z-plasty
12
20
M
PT rerouting
FCU to ECRB, FCR FL
FDS FL, FDP FL
EPL rerouting, MCP volar capsulodesis
13
17
F
STP
FPL z-plasty
14
28
M
Wrist fusion
15
28
F
Wrist fusion
Wrist fusion
CT tenotomy in index and middle fingers
Lateral band rerouting in the index through ring fingers
STP
FPL z-plasty EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
PT, pronator teres; FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FL, fractional lengthening; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus; CT, central tendon; AP, adductor pollicis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; STP, superficialis transfer to profundus.
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
TABLE 3.
Comparison of Groups Group 1
Age, y Procedures, n Follow-up, mo
Group 2
21 12 (6 to 54)
20 6 (17 to 34)
5.4 3.5 (2 to 12)
6.8 3.1 (1 to 10)
72 15 (48 to 96)
31 16 (12 to 57)
P Value .77 .28 < .01
House class Preoperative
2.9 1.4 (1 to 5)
2.9 1.5 (1 to 6)
.89
Postoperative
4.7 1.4 (4 to 7)
4.7 1.6 (2 to 7)
.93
Change
1.9 0.5 (1 to 3)
1.8 0.7 (1 to 3)
.80
Flexion posture ( ) Preoperative
91 21 (50 to 130)
95 22 (60 to 130)
.63
Postoperative
48 13 (15 to 70)
43 15 (20 to 70)
.53
Change
44 10 (20 to 60)
53 12 (40 to 70)
.04
Preoperative
9 10 (0 to 30)
12 11 (0 to 30)
.49
Postoperative
7 7 (0 to 30)
9 10 (0 to 30)
.56
Change
3 5 (0 to 15)
3 5 (0 to 10)
.95
Preoperative
e38 16 (e60 to e20)
e39 21 (e80 to e20)
.91
Postoperative
e23 14 (e45 to 0)
e16 8 (e30 to 0)
.18
15 5 (10 to 25)
23 13 (10 to 50)
.04 .58
Flexion contracture ( )
Active extension ( )
Change Active flexion ( ) Preoperative
141 5 (130 to 145)
142 4 (130 to 145)
Postoperative
140 5 (130 to 145)
135 7 (120 to 145)
Change
e1 2 (e5 to 0)
e7 6 (e20 to 0)
.02 < .01
Data are presented as mean standard deviation (range). Bolded values indicate statistical significance.
the elbow flexed 90 , and the forearm in the neutral. Primary caregivers obtained preoperative and postoperative House functional levels by regarding hand use during daily activities.14 The 9-level House functional classification system assesses functional use of the hand as: does not use (class 0), passive assist (poor, class 1; fair, class 2; and good, class 3), active assist (poor, class 4; fair, class 5; and good, class 6), and spontaneous use (partial, class 7; and complete, class 8).14 Because the follow-up periods were different for the 2 groups, we first determined whether outcomes were stable over time in group 1. We compared earlier follow-up data with a mean 30 months’ follow-up (range, 12e60 mo), which was 3 years earlier than the latest follow-up and similar to those of group 2, with the latest follow-up data using a paired t test. There were no significant differences in the measured parameters between the 2 datasets. Therefore, we compared the latest data of group 1 with the data from group 2. We used Student t test for
a method similar to that described by Manske et al.3 For ambulatory patients, we measured the flexion posture while they were instructed to walk a short distance repeatedly inside the examination room until the flexion posture of the affected extremity became consistent, and then the examiner held the arm in that position and measured the angle. For nonambulatory patients, we measured the elbow flexion posture in sitting position while they were instructed to perform a task such as drawing or writing using the contralateral extremity. We measured active elbow flexion when patients actively flexed the elbow to the maximum (180 minus the angle between the 2 arms of the goniometer), active extension when patients actively extended the elbow to the maximum (the angle between the 2 arms of the goniometer minus 180 ), and flexion contracture when the examiner passively extended the elbow to the maximum (180 minus the angle between the 2 arms of the goniometer). Active forearm pronation and supination were also measured with the shoulder adducted to the side, J Hand Surg Am.
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
TABLE 4.
Comparison of Forearm Supination and Pronation Group 1
Group 2
P Value
Preoperative
11 23 (e30 to 40)
12 21 (e30 to 40)
.91
Postoperative
36 14 (10 to 50)
38 9 (20 to 50)
.72
Change
25 16 (e10 to 40)
Active supination
26 19 (0 to 60)
.92
Active pronation Preoperative
73 6 (60 to 80)
Postoperative
71 11 (40 to 80)
61 11 (50 to 80)
.02
2 8 (0 to 30)
e9 10 (e20 to 0)
< .01
Change
70 6 (60 to 80)
.21
Data are presented as mean standard deviation (range). Bolded value indicates statistical significance.
improvement between groups. There was a mean 9 decrease in active pronation in group 2 (Table 4).
group comparisons and paired t test to compare perioperative changes of the parameters within the groups. P < .05 was considered significant.
DISCUSSION We found that partial lengthening of the biceps tendon improved elbow flexion posture and active elbow extension in patients with flexion deformity in CP. Furthermore, partial biceps lengthening did not affect active forearm supination when appropriate supination procedures were simultaneously performed, although this could have resulted from the larger effect of supination procedures rather than from the lack of effect of biceps lengthening. Carlson et al4 reported outcomes of partial elbow muscle lengthening that included partial lengthening of the biceps and brachialis and proximal release of the brachioradialis in 74 elbows of 71 patients who did not have fixed elbow flexion contracture more than 45 . They reported that the elbow flexion posture improved from 89 to 32 and active elbow extension improved from 23 from neutral to 7 from neutral with a 4 loss of active flexion. Carlson et al reported their long-term follow-up results in 23 patients at a mean follow-up of 9 years, at which time active elbow extension and elbow flexion posture improved 12 and 63 , respectively, with an 8 loss of active flexion. This result is comparable to a 7 loss in our study.15 They lengthened the biceps similar to our technique and also released the brachioradialis, a procedure we did not perform. Keenan et al5 reported that the most severe spasticity was noted in the brachioradialis muscle, followed by the biceps and brachialis in patients with brain injury with elbow flexion spasticity. Although Manske et al3 did not release the brachioradialis in their study, either, they noted that release of the brachioradialis should be considered to attain more improvement in extension.
RESULTS The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House class scores, except for the follow-up period, which was shorter in group 2 (Table 3). Including the anterior elbow release, group 1 patients had a mean of 5.4 procedures (range, 2e12 procedures) per person, and group 2 patients had a mean of 6.8 procedures (range, 1e10 procedures) as single-event multilevel upper extremity surgery, in which 1 procedure was equivalent to 1 bone and joint or tendon surgery (Tables 1, 2). The mean House class scores improved in both groups without statistically significant differences between groups (Table 3). Mean flexion posture significantly improved in both groups. The mean change in flexion posture was significantly larger in group 2 (53 ) than in group 1 (44 ). Mean active extension significantly improved in both groups. The mean improvement was significantly larger in group 2 (23 ) than in group 1 (15 ). Mean active flexion did not change in group 1, but there was a significant mean decrease of 7 in group 2. There was no significant difference in mean flexion contracture between groups (Table 3). Mean preoperative active supination was 11 in group 1 and 12 in group 2. Thirteen of 14 patients in group 1 and 10 of 15 in group 2 underwent soft tissue procedures to increase forearm supination (pronator teres rerouting or tenotomy, and/or transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis). One patient in group 1 required osteotomy of both forearm bones. Postoperatively, mean active supination significantly improved in both groups. There was no statistically significant difference in J Hand Surg Am.
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
However, the final House class scores were not different between groups, and the outcomes were stable over time in group 1. Dy et al15 also reported no significant changes in parameters between short-term and long-term follow up. A further study is necessary to evaluate long-term outcomes. Fourth, anterior elbow release is traditionally performed in children or adolescents, but this study included many adult patients. This was because hand surgeons at our institution only recently began to treat upper extremity problems in CP; thus, pediatric orthopedic surgeons referred many adult patients whom they had previously treated. Finally, we did had no patients with a severe fixed flexion deformity that might have required zlengthening of the biceps and capsular release. Therefore, the results of this study may not be applicable to those with a severe elbow flexion deformity.
The literature has shown that conservative treatment of distal biceps tendon rupture results in a mean loss of 40% of supination strength.16 Mital1 reported a 10 loss of supination in 1 patient after z- lengthening of the biceps in patients with CP. Although it would be difficult to isolate the effect of biceps lengthening on forearm supination with simultaneous forearm supination procedures, we compared forearm rotation between groups. Fewer patients in group 2 received the supination procedures compared with group 1; however, mean active supination improved similarly in both groups. Repair of chronic biceps tendon ruptures using hamstring tendon, which is similar to lengthening of the biceps tendon, has shown that supination strength increased from 33% to 90% of the contralateral side, and flexion strength from 81% to 92%.17 Because the biceps muscletendon unit healed in a lengthened state restore both supination and flexion strength to 90% in patients with chronic biceps rupture, we are not sure why patients with CP have a loss of active flexion when supination loss is not evident. We suspect that lengthening of the biceps may decrease the excursion of the muscle. It may therefore affect full flexion of the elbow more than full supination, because the excursion should be larger for elbow flexion than for forearm supination. When we lengthened the brachialis, a stronger flexor with its large cross-sectional area and shorter excursion than the biceps, the only muscle that could perform full elbow flexion may have been the biceps. Therefore, we consider that biceps lengthening in addition to brachialis lengthening may risk the loss of elbow flexion, whereas biceps rupture with intact brachialis does not affect full elbow flexion. There are several limitations to this study. First, the study population was small. Retrospective power analysis indicated that our study was underpowered at 72%. If we attempted to determine a difference of 10 elbow flexion posture angle between groups, with an SD of 10 for an effect size of 1.0, a sample size of 17 would be necessary to provide 80% statistical power. Second, this was a retrospective study without randomization or blinding of the groups, which could have resulted in selection bias. However, because consecutive patients were reviewed and the procedures were changed at a single time point, we consider selection bias to have been minimal. Furthermore, the 2 groups were comparable in terms of demographics and preoperative functional status. Third, the follow-up period of group 2 was short. Spasticity and deformity may recur with a longer follow-up period, and muscle strength may not recover fully with a short follow-up. J Hand Surg Am.
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REFERENCES 1. Mital MA. Lengthening of the elbow flexors in cerebral palsy. J Bone Joint Surg Am. 1979;61(4):515e522. 2. Koman LA, Gelberman RH, Toby EB, Poehling GG. Cerebral palsy: management of the upper extremity. Clin Orthop Relat Res. 1990;(253):62e74. 3. Manske PR, Langewisch KR, Strecker WB, Albrecht MM. Anterior elbow release of spastic elbow flexion deformity in children with cerebral palsy. J Pediatr Orthop. 2001;21(6):772e777. 4. Carlson MG, Hearns KA, Inkellis E, Leach ME. Early results of surgical intervention for elbow deformity in cerebral palsy based on degree of contracture. J Hand Surg Am. 2012;37(8):1665e1671. 5. Keenan MA, Haider TT, Stone LR. Dynamic electromyography to assess elbow spasticity. J Hand Surg Am. 1990;15(4):607e614. 6. Carson M. Cerebral palsy. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 2005:1197e1234. 7. Van Heest AE, House JH, Cariello C. Upper extremity surgical treatment of cerebral palsy. J Hand Surg Am. 1999;24(2):323e330. 8. Gschwind CR. Surgical management of forearm pronation. Hand Clin. 2003;19(4):649e655. 9. Bunata RE. Pronator teres rerouting in children with cerebral palsy. J Hand Surg Am. 2006;31(3):474e482. 10. Carlson MG, Athwal GS, Bueno RA. Treatment of the wrist and hand in cerebral palsy. J Hand Surg Am. 2006;31(3):483e490. 11. Rayan GM, Young BT. Arthrodesis of the spastic wrist. J Hand Surg Am. 1999;24(5):944e952. 12. Van Heest AE. Surgical management of wrist and finger deformity. Hand Clin. 2003;19(4):657e665. 13. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for swan-neck deformity. J Hand Surg Am. 1992;17(2):260e267. 14. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am. 1981;63(2):216e225. 15. Dy CJ, Pean CA, Hearns KA, Swanstrom MM, Janowski LC, Carlson MG. Long-term results following surgical treatment of elbow deformity in patients with cerebral palsy. J Hand Surg Am. 2013;38(12):2432e2436. 16. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am. 1985;67(3):418e421. 17. Hallam P, Bain GI. Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the Endobutton. J Shoulder Elbow Surg. 2004;13(6):648e651.
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Early Results of Anterior Elbow Release With and Without Biceps Lengthening in Patients With Cerebral Palsy Hyun Sik Gong, MD, Hoyune Esther Cho, MS, Chin Youb Chung, MD, Moon Seok Park, MD, Hyuk Jin Lee, MD, Goo Hyun Baek, MD Purpose To investigate the effect of partial biceps lengthening on elbow flexion posture and active elbow flexion and extension in patients with cerebral palsy. Methods We retrospectively reviewed 29 patients with cerebral palsy who underwent anterior elbow release as part of multilevel upper extremity surgery. The early series of the patients (N ¼ 14; group 1) had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous adventitia off the biceps tendon. The later series of patients (N ¼ 15; group 2) had partial biceps tendon lengthening in addition to the procedures in group 1. We compared the 2 sets of patients for elbow flexion posture, active elbow flexion and extension, forearm rotation, and House scores, with mean follow-ups of 72 months for group 1 and 31 months for group 2. Results The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House scores. Group 2 patients had more improvement in flexion posture (53 vs 44 ) and active extension (23 vs 15 ) than group 1 postoperatively. However, group 2 had a mean decrease of 7 in active elbow flexion, whereas group 1 had no changes. There was no difference in forearm supination or in the improvement of House scores between groups. Conclusions Early results of partial lengthening of the biceps tendon showed that it may improve elbow flexion posture and active elbow extension in patients with flexion deformity in cerebral palsy. (J Hand Surg Am. 2014;39(5):902e909. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic III. Key words Cerebral palsy, flexion deformity, anterior elbow release, biceps lengthening. flexion deformity is caused by spasticity of the biceps, brachialis, and brachioradialis in patients with cerebral palsy (CP).1e4 Elbow flexion deformity can interfere
E
LBOW FLEXION POSTURE OR
From the Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; and the Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea. Received for publication December 6, 2013; accepted in revised form February 14, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Hyun Sik Gong, MD, Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; e-mail: hsgong@ snu.ac.kr. 0363-5023/14/3905-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.02.012
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with hand positioning for functional activities and is of aesthetic concern as the deformity becomes more pronounced during ambulation.3e5 To improve elbow flexion deformity or spasticity, several surgical treatments have been performed, such as neurectomy of the musculocutaneous nerve, release of the flexorpronator muscle from the medial epicondyle, and lengthening of the anterior elbow muscles.6 Because the musculocutaneous nerve has been cut only for mild contractures and because flexorepronator muscle release has been shown to have less of an effect at the elbow than at the hand, lengthening of the anterior elbow muscles is considered the standard surgical treatment of elbow flexion deformity.1,3,4,7 For anterior elbow release, Mital1 performed a division of the lacertus fibrosus, z-plasty of the biceps,
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
and fractional lengthening of the brachialis, and reported improvement in flexion contracture from 48 to 10 . Although Mital reported no loss of elbow flexion, he noticed weakness of supination in 1 patient, which may have resulted from lengthening of the biceps, a principal supinator of the forearm. Manske et al3 pointed out that this potential risk of supination loss is a major concern in patients with CP, who usually have a pronation deformity of the forearm. They modified the procedure of Mital: Instead of lengthening the biceps, they denuded the pretendinous adventitia off the biceps, potentially removing afferent nerve fibers and receptors. However, Carlson et al4 performed partial lengthening of the biceps (sliding without z-plasty lengthening) in patients with fixed elbow contractures less than 45 and reported greater reduction in elbow flexion posture compared with the results of Manske et al (57 improvement vs 49 ), which they attributed to partial lengthening of the biceps tendon. However, their study was a case series without an internal control group. For patients with fixed flexion contracture less than 45 , we used the procedure of Manske et al3 for anterior elbow release in our earlier patients; later, we added partial lengthening of the biceps tendon. The purpose of this study was to compare the outcomes of the 2 sets of procedures done by a single surgeon, to determine the effect of partial lengthening of the biceps tendon on elbow flexion posture and active elbow flexion and extension.
included 14 with a mean age of 21 years (SD, 12 y; range, 6e54 y) and the later patients (group 2) included 15 patients with a mean age of 20 years (SD, 5 y; range, 10e34 y). Group 1 patients were reviewed with a mean follow-up of 72 months (range, 48e96 mo) and group 2 patients were reviewed with a mean follow-up of 31 months (range, 12e54 mo). Group 1 included 9 males and 5 females, and group 2 had 11 males and 4 females. All patients had spastic hemiplegia or tetraplegia, and no patients were ataxic or dyskinetic. Surgical procedures For anterior elbow release in group 1, we made a transverse incision over the antecubital fossa, divided the lacertus fibrosus (Fig. 1), and fractionally lengthened the brachialis muscle by making 2 transverse incisions spanning the entire width of the aponeurosis over the muscle and extending the elbow (Fig. 2). We did not cut the brachialis muscle fibers. Then, we stripped the adventitia off the length of the biceps tendon to disrupt afferent nerve fibers, as described by Manske et al.3 For group 2 patients, we added partial lengthening of the biceps tendon to the procedure. We made 2 transverse incisions 3 cm apart (1 on the medial half of the tendon and the other on the lateral half), and extended the elbow to separate these 2 partial tenotomy sites (Fig. 3). We placed 2 nonabsorbable sutures between the 2 tenotomy sites to prevent further splitting of the fibers (Fig. 4).6 We did not perform z-plasty lengthening of the biceps tendon, brachioradialis release, or capsular or ligamentous release of the elbow. In addition to anterior elbow release, patients received other upper extremity procedures as singleevent multilevel upper extremity surgery. There was no change in principles and techniques throughout the study period. Tables 1 and 2 present the additional surgical procedures patients received. For forearm deformity, we performed pronator rerouting for absent or weak active supination, pronator tenotomy for active supination short of neutral, and rotational osteotomy for a fixed pronation deformity.8,9 For wrist deformity, we transferred the flexor carpi ulnaris to the extensor carpi radialis brevis for patients with wrist flexion deformity and transferred the extensor carpi ulnaris to the extensor carpi radialis brevis with fractional lengthening of the wrist flexors for patients with primarily wrist ulnar deviation deformity.10 We performed wrist arthrodesis in patients with fixed flexion contracture of the wrist.11 For the fingers, we fractionally lengthened the digital flexor tendons for tight flexors and sometimes
MATERIALS AND METHODS Subjects We reviewed patients with CP who underwent singleevent, multilevel upper extremity surgery between May 2004 and March 2012. All procedures were done by the same hand surgeon (H.G.). Our institutional review board approved this study. A total of 31 patients underwent anterior elbow release, and 29 of them with follow-up of more than 1 year and complete data were included in this study. The indication for surgery was a preoperative flexion posture of greater than 50 with activities.3 Earlier patients (May 2004 to March 2008) had anterior elbow release procedure for elbow flexion posture, described by Manske et al3: division of the lacertus fibrosus, fractional lengthening of the brachialis, and denuding of the pretendinous adventitia of the biceps tendon. The later patients (April 2008 to March 2012) had the same procedures and added fractional lengthening of the biceps tendon.6 The earlier patients (group 1) J Hand Surg Am.
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FIGURE 1: We made a transverse incision on the elbow and divided the lacertus fibrosus (dashed line) (left elbow; the left side is proximal).
FIGURE 3: After stripping the adventitia off the biceps tendon, we made 2 transverse incisions 3 cm apart: 1 on the medial half of the tendon and the other on the lateral half.
FIGURE 2: We fractionally lengthened the brachialis muscle by making 2 transverse incisions (white arrows) spanning the entire width of the aponeurosis over the muscle, and then extending the elbow.
FIGURE 4: We extended the elbow to separate the 2 partial tenotomy sites of the biceps tendon and placed nonabsorbable sutures (black arrow) to prevent further splitting of the fibers.
a long-arm cast for 4 weeks after tendon transfer surgery and for 6 weeks after arthrodesis or osteotomy, and then patients started physiotherapy. We did not employ long-term splinting of the elbow.
performed flexor digitorum superficialis to flexor digitorum profundus transfer for patients who were not able to passively extend the fingers with the wrist in flexion.12 For thumb-in-palm deformity, we performed z-plasty lengthening of the first web, proximal advancement of the adductor pollicis insertion, and rerouting of the extensor pollicis longus.10 We also performed fractional lengthening of the flexor pollicis longus in patients with flexed thumb interphalangeal joint and volar capsulodesis for hyperextension of the metacarpophalangeal joint.12 For severe swan-neck deformities, we usually performed central tendon tenotomy or sometimes lateral band rerouting in patients with severe laxity of the volar plate.13 Postoperatively, we immobilized patients with J Hand Surg Am.
Outcome evaluation and analyses A research assistant (orthopedic research nurse) measured elbow flexion posture, active elbow flexion and extension, and elbow flexion contracture preoperatively and at each postoperative visit. The examiner placed the goniometer axis over the lateral epicondyle, the stationary arm parallel to the longitudinal axis of the humerus pointing to the tip of the acromion, and the moving arm parallel to the longitudinal axis of the forearm pointing to the middle portion of the wrist. Elbow flexion posture was measured using r
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TABLE 1.
Procedures Performed on Group 1 Patients (Anterior Elbow Release With Denuding of Pretendinous Adventitia of Biceps)
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Age
Sex
Forearm Pronation
Wrist Flexion
Swan Neck
Finger Flexion
Thumb-in-Palm
1
12
M
2
13
M
3
20
M
PT tenotomy
4
54
M
PT tenotomy
5
13
F
ECU to ECRB
6
16
F
FCU to ECRB
7
17
M
8
22
M
ECU to ECRB
FDS FL, FDP FL
9
25
M
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
10
6
F
PT tenotomy
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis
11
20
M
PT rerouting
FCU to ECRB
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
12
21
M
FCU to ECRB, FCR FL
STP
FPL FL
13
25
F
PT rerouting
FCU to ECRB
STP
Web deepening, EPL rerouting, AP advancement, FPL z-plasty
14
35
F
PT rerouting
ECU to ECRB, FCU FL
PT rerouting FCU to ECRB
Radial and ulnar osteotomy
FCU to ECRB
FCU to ECRB, FCR FL
FDS FL, FDP FL
CT tenotomy in index and middle fingers
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
J Hand Surg Am.
Patient
Web deepening, EPL rerouting, AP advancement
PT, pronator teres; FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FL, fractional lengthening; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus; CT, central tendon; AP, adductor pollicis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; STP, superficialis transfer to profundus; ECU, extensor carpi ulnaris.
905
906
TABLE 2.
Procedures Performed on Group 2 Patients (Anterior Elbow Release With Lengthening of Biceps Tendon)
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Age
Sex
Forearm Pronation
Wrist Flexion
1
20
M
2
34
M
3
17
M
PT rerouting
FCU to ECRB
4
18
F
PT rerouting
FCU to ECRB
5
25
M
FCU to ECRB, FCR FL
6
24
M
FCU to ECRB
7
14
M
8
16
9
Swan Neck
Finger Flexion
FDS FL, FDP FL
Thumb-in-Palm
FPL FL EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
FDS FL, FDP FL
FPL FL
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
F
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
14
M
FCU to ECRB, FCR FL
FDS FL, FDP FL
Web deepening, EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
10
22
M
PT tenotomy
Wrist fusion
FDS FL, FDP FL
FPL FL
11
21
M
FCU to ECRB, FCR FL
STP
FPL z-plasty
12
20
M
PT rerouting
FCU to ECRB, FCR FL
FDS FL, FDP FL
EPL rerouting, MCP volar capsulodesis
13
17
F
STP
FPL z-plasty
14
28
M
Wrist fusion
15
28
F
Wrist fusion
Wrist fusion
CT tenotomy in index and middle fingers
Lateral band rerouting in the index through ring fingers
STP
FPL z-plasty EPL rerouting, AP advancement, MCP volar capsulodesis, FPL FL
PT, pronator teres; FCU, flexor carpi ulnaris; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FL, fractional lengthening; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus; CT, central tendon; AP, adductor pollicis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; STP, superficialis transfer to profundus.
BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
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Patient
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
TABLE 3.
Comparison of Groups Group 1
Age, y Procedures, n Follow-up, mo
Group 2
21 12 (6 to 54)
20 6 (17 to 34)
5.4 3.5 (2 to 12)
6.8 3.1 (1 to 10)
72 15 (48 to 96)
31 16 (12 to 57)
P Value .77 .28 < .01
House class Preoperative
2.9 1.4 (1 to 5)
2.9 1.5 (1 to 6)
.89
Postoperative
4.7 1.4 (4 to 7)
4.7 1.6 (2 to 7)
.93
Change
1.9 0.5 (1 to 3)
1.8 0.7 (1 to 3)
.80
Flexion posture ( ) Preoperative
91 21 (50 to 130)
95 22 (60 to 130)
.63
Postoperative
48 13 (15 to 70)
43 15 (20 to 70)
.53
Change
44 10 (20 to 60)
53 12 (40 to 70)
.04
Preoperative
9 10 (0 to 30)
12 11 (0 to 30)
.49
Postoperative
7 7 (0 to 30)
9 10 (0 to 30)
.56
Change
3 5 (0 to 15)
3 5 (0 to 10)
.95
Preoperative
e38 16 (e60 to e20)
e39 21 (e80 to e20)
.91
Postoperative
e23 14 (e45 to 0)
e16 8 (e30 to 0)
.18
15 5 (10 to 25)
23 13 (10 to 50)
.04 .58
Flexion contracture ( )
Active extension ( )
Change Active flexion ( ) Preoperative
141 5 (130 to 145)
142 4 (130 to 145)
Postoperative
140 5 (130 to 145)
135 7 (120 to 145)
Change
e1 2 (e5 to 0)
e7 6 (e20 to 0)
.02 < .01
Data are presented as mean standard deviation (range). Bolded values indicate statistical significance.
the elbow flexed 90 , and the forearm in the neutral. Primary caregivers obtained preoperative and postoperative House functional levels by regarding hand use during daily activities.14 The 9-level House functional classification system assesses functional use of the hand as: does not use (class 0), passive assist (poor, class 1; fair, class 2; and good, class 3), active assist (poor, class 4; fair, class 5; and good, class 6), and spontaneous use (partial, class 7; and complete, class 8).14 Because the follow-up periods were different for the 2 groups, we first determined whether outcomes were stable over time in group 1. We compared earlier follow-up data with a mean 30 months’ follow-up (range, 12e60 mo), which was 3 years earlier than the latest follow-up and similar to those of group 2, with the latest follow-up data using a paired t test. There were no significant differences in the measured parameters between the 2 datasets. Therefore, we compared the latest data of group 1 with the data from group 2. We used Student t test for
a method similar to that described by Manske et al.3 For ambulatory patients, we measured the flexion posture while they were instructed to walk a short distance repeatedly inside the examination room until the flexion posture of the affected extremity became consistent, and then the examiner held the arm in that position and measured the angle. For nonambulatory patients, we measured the elbow flexion posture in sitting position while they were instructed to perform a task such as drawing or writing using the contralateral extremity. We measured active elbow flexion when patients actively flexed the elbow to the maximum (180 minus the angle between the 2 arms of the goniometer), active extension when patients actively extended the elbow to the maximum (the angle between the 2 arms of the goniometer minus 180 ), and flexion contracture when the examiner passively extended the elbow to the maximum (180 minus the angle between the 2 arms of the goniometer). Active forearm pronation and supination were also measured with the shoulder adducted to the side, J Hand Surg Am.
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
TABLE 4.
Comparison of Forearm Supination and Pronation Group 1
Group 2
P Value
Preoperative
11 23 (e30 to 40)
12 21 (e30 to 40)
.91
Postoperative
36 14 (10 to 50)
38 9 (20 to 50)
.72
Change
25 16 (e10 to 40)
Active supination
26 19 (0 to 60)
.92
Active pronation Preoperative
73 6 (60 to 80)
Postoperative
71 11 (40 to 80)
61 11 (50 to 80)
.02
2 8 (0 to 30)
e9 10 (e20 to 0)
< .01
Change
70 6 (60 to 80)
.21
Data are presented as mean standard deviation (range). Bolded value indicates statistical significance.
improvement between groups. There was a mean 9 decrease in active pronation in group 2 (Table 4).
group comparisons and paired t test to compare perioperative changes of the parameters within the groups. P < .05 was considered significant.
DISCUSSION We found that partial lengthening of the biceps tendon improved elbow flexion posture and active elbow extension in patients with flexion deformity in CP. Furthermore, partial biceps lengthening did not affect active forearm supination when appropriate supination procedures were simultaneously performed, although this could have resulted from the larger effect of supination procedures rather than from the lack of effect of biceps lengthening. Carlson et al4 reported outcomes of partial elbow muscle lengthening that included partial lengthening of the biceps and brachialis and proximal release of the brachioradialis in 74 elbows of 71 patients who did not have fixed elbow flexion contracture more than 45 . They reported that the elbow flexion posture improved from 89 to 32 and active elbow extension improved from 23 from neutral to 7 from neutral with a 4 loss of active flexion. Carlson et al reported their long-term follow-up results in 23 patients at a mean follow-up of 9 years, at which time active elbow extension and elbow flexion posture improved 12 and 63 , respectively, with an 8 loss of active flexion. This result is comparable to a 7 loss in our study.15 They lengthened the biceps similar to our technique and also released the brachioradialis, a procedure we did not perform. Keenan et al5 reported that the most severe spasticity was noted in the brachioradialis muscle, followed by the biceps and brachialis in patients with brain injury with elbow flexion spasticity. Although Manske et al3 did not release the brachioradialis in their study, either, they noted that release of the brachioradialis should be considered to attain more improvement in extension.
RESULTS The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House class scores, except for the follow-up period, which was shorter in group 2 (Table 3). Including the anterior elbow release, group 1 patients had a mean of 5.4 procedures (range, 2e12 procedures) per person, and group 2 patients had a mean of 6.8 procedures (range, 1e10 procedures) as single-event multilevel upper extremity surgery, in which 1 procedure was equivalent to 1 bone and joint or tendon surgery (Tables 1, 2). The mean House class scores improved in both groups without statistically significant differences between groups (Table 3). Mean flexion posture significantly improved in both groups. The mean change in flexion posture was significantly larger in group 2 (53 ) than in group 1 (44 ). Mean active extension significantly improved in both groups. The mean improvement was significantly larger in group 2 (23 ) than in group 1 (15 ). Mean active flexion did not change in group 1, but there was a significant mean decrease of 7 in group 2. There was no significant difference in mean flexion contracture between groups (Table 3). Mean preoperative active supination was 11 in group 1 and 12 in group 2. Thirteen of 14 patients in group 1 and 10 of 15 in group 2 underwent soft tissue procedures to increase forearm supination (pronator teres rerouting or tenotomy, and/or transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis). One patient in group 1 required osteotomy of both forearm bones. Postoperatively, mean active supination significantly improved in both groups. There was no statistically significant difference in J Hand Surg Am.
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BICEPS LENGTHENING IN ANTERIOR ELBOW RELEASE
However, the final House class scores were not different between groups, and the outcomes were stable over time in group 1. Dy et al15 also reported no significant changes in parameters between short-term and long-term follow up. A further study is necessary to evaluate long-term outcomes. Fourth, anterior elbow release is traditionally performed in children or adolescents, but this study included many adult patients. This was because hand surgeons at our institution only recently began to treat upper extremity problems in CP; thus, pediatric orthopedic surgeons referred many adult patients whom they had previously treated. Finally, we did had no patients with a severe fixed flexion deformity that might have required zlengthening of the biceps and capsular release. Therefore, the results of this study may not be applicable to those with a severe elbow flexion deformity.
The literature has shown that conservative treatment of distal biceps tendon rupture results in a mean loss of 40% of supination strength.16 Mital1 reported a 10 loss of supination in 1 patient after z- lengthening of the biceps in patients with CP. Although it would be difficult to isolate the effect of biceps lengthening on forearm supination with simultaneous forearm supination procedures, we compared forearm rotation between groups. Fewer patients in group 2 received the supination procedures compared with group 1; however, mean active supination improved similarly in both groups. Repair of chronic biceps tendon ruptures using hamstring tendon, which is similar to lengthening of the biceps tendon, has shown that supination strength increased from 33% to 90% of the contralateral side, and flexion strength from 81% to 92%.17 Because the biceps muscletendon unit healed in a lengthened state restore both supination and flexion strength to 90% in patients with chronic biceps rupture, we are not sure why patients with CP have a loss of active flexion when supination loss is not evident. We suspect that lengthening of the biceps may decrease the excursion of the muscle. It may therefore affect full flexion of the elbow more than full supination, because the excursion should be larger for elbow flexion than for forearm supination. When we lengthened the brachialis, a stronger flexor with its large cross-sectional area and shorter excursion than the biceps, the only muscle that could perform full elbow flexion may have been the biceps. Therefore, we consider that biceps lengthening in addition to brachialis lengthening may risk the loss of elbow flexion, whereas biceps rupture with intact brachialis does not affect full elbow flexion. There are several limitations to this study. First, the study population was small. Retrospective power analysis indicated that our study was underpowered at 72%. If we attempted to determine a difference of 10 elbow flexion posture angle between groups, with an SD of 10 for an effect size of 1.0, a sample size of 17 would be necessary to provide 80% statistical power. Second, this was a retrospective study without randomization or blinding of the groups, which could have resulted in selection bias. However, because consecutive patients were reviewed and the procedures were changed at a single time point, we consider selection bias to have been minimal. Furthermore, the 2 groups were comparable in terms of demographics and preoperative functional status. Third, the follow-up period of group 2 was short. Spasticity and deformity may recur with a longer follow-up period, and muscle strength may not recover fully with a short follow-up. J Hand Surg Am.
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REFERENCES 1. Mital MA. Lengthening of the elbow flexors in cerebral palsy. J Bone Joint Surg Am. 1979;61(4):515e522. 2. Koman LA, Gelberman RH, Toby EB, Poehling GG. Cerebral palsy: management of the upper extremity. Clin Orthop Relat Res. 1990;(253):62e74. 3. Manske PR, Langewisch KR, Strecker WB, Albrecht MM. Anterior elbow release of spastic elbow flexion deformity in children with cerebral palsy. J Pediatr Orthop. 2001;21(6):772e777. 4. Carlson MG, Hearns KA, Inkellis E, Leach ME. Early results of surgical intervention for elbow deformity in cerebral palsy based on degree of contracture. J Hand Surg Am. 2012;37(8):1665e1671. 5. Keenan MA, Haider TT, Stone LR. Dynamic electromyography to assess elbow spasticity. J Hand Surg Am. 1990;15(4):607e614. 6. Carson M. Cerebral palsy. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier; 2005:1197e1234. 7. Van Heest AE, House JH, Cariello C. Upper extremity surgical treatment of cerebral palsy. J Hand Surg Am. 1999;24(2):323e330. 8. Gschwind CR. Surgical management of forearm pronation. Hand Clin. 2003;19(4):649e655. 9. Bunata RE. Pronator teres rerouting in children with cerebral palsy. J Hand Surg Am. 2006;31(3):474e482. 10. Carlson MG, Athwal GS, Bueno RA. Treatment of the wrist and hand in cerebral palsy. J Hand Surg Am. 2006;31(3):483e490. 11. Rayan GM, Young BT. Arthrodesis of the spastic wrist. J Hand Surg Am. 1999;24(5):944e952. 12. Van Heest AE. Surgical management of wrist and finger deformity. Hand Clin. 2003;19(4):657e665. 13. Tonkin MA, Hughes J, Smith KL. Lateral band translocation for swan-neck deformity. J Hand Surg Am. 1992;17(2):260e267. 14. House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in palm deformity in cerebral palsy. J Bone Joint Surg Am. 1981;63(2):216e225. 15. Dy CJ, Pean CA, Hearns KA, Swanstrom MM, Janowski LC, Carlson MG. Long-term results following surgical treatment of elbow deformity in patients with cerebral palsy. J Hand Surg Am. 2013;38(12):2432e2436. 16. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am. 1985;67(3):418e421. 17. Hallam P, Bain GI. Repair of chronic distal biceps tendon ruptures using autologous hamstring graft and the Endobutton. J Shoulder Elbow Surg. 2004;13(6):648e651.
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