POSTOPERATIVE MIGRATION OF THE ADDUCTOR TENDON AFTER POSTERIOR ADDUCTOR TRANSFER IN CHILDREN WITH CEREBRAL PALSY Randall T. Loder Alan Harbuz David D. Aronson Christopher L. Lee
A common hip deformity of children with spastic cerebral palsy is an adduction contracture (Banks and Green 1960, Samilson et al. 1967, Root and Spero 1981). Before severe hip subluxation has developed, soft-tissue procedures alone can improve the contractures and decrease the scissoring gait pattern, and often can improve the hip subluxation when mild. The two most common softtissue procedures are adductor tenotomy, with or without anterior branch obturator neurectomy (Keats 1957, Banks and Green 1960, Matsuo et al. 1986), and posterior transfer of the adductor longus and gracilis tendons to the ischiurn, with or without the adductor brevis and magnus (Stephenson and Donovan 1969, Baumann et al. 1978, Root and Spero 1981, Reimers and Paulsen 1984, Aronson et al. 1991). Although the transfer usually requires a longer operative time and is technically more difficult, several authors feel it is a better procedure (Couch et al. 1977, Baumann et al. 1978, Matsuo et al. 1986), imparting some hip extension and reducing the risk of overcorrection or creation of an abduction contracture (Samilson et al. 1967, Griffin el a/. 1977, Matsuo et al. 1986). Aronson et al. (1991), in a recent review of the posterior adductor transfer, generally found satisfactory results, with the transfer doing better in children with spastic diplegia
than with spastic quadriplegia. However, the question arose as to whether the newly transferred tendon remains attached to the ischium. If it pulls away, then in essence the transfer becomes an adductor tenotomy. T o answer this question we undertook a review of children undergoing adductor transfer, in which the newly transferred tendons had been tagged with metallic markers and followed over time.
Material and method
Three staff orthopaedists at the Detroit Institute for Children (outpatient unit) and the Children's Hospital of Michigan (inpatient unit), (Detroit, MI), began personally to follow their own adductor transfers by tagging the adductor longus tendon. 17 children (eight boys and nine girls) with spastic cerebral palsy who had undergone posterior adductor transfers on 33 hips comprised the study group. Seven children had spastic quadriplegia and 10 had spastic diplegia. The average age at surgery was 5 years 3 months (range 1 year 9 months t o 15 years 10 months), 4 years 11 months for the spastic quadriplegic children and 5 years 9 months for the spastic diplegic children. The surgical technique of the posterior adductor transfer, as described by Root and Spero (1981), was used. The operative procedure was performed through a groin incision, beginning at the origin of the
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adductor longus and extending 8cm toward the ischial tuberosity. The origins of the adductor longus and gracilis were removed subperiosteally and transferred posteriorly. They were sutured directly to the ischial tuberosity and/or its periosteum, using 0-size non-absorbable sutures (coated polyester, e.g. ‘Ethibond’). The sutures were anchored directly into the ischial tuberosity using a very sturdy, sharp-pointed needle. In younger children, the ischiopubic junction is cartilagenous and in this circumstance the suturing is easier by direct suture into cartilage. If the suture could not be passed through the ischial tuberosity proper (e.g. too hard for needle passage) its periosteum or perichondrium was used. The origins of the adductor brevis and anterior portion of the adductor magnus were released (myotomy). Obturator neurectomy was not performed. After the adductor longus tendon transfer had been sutured into the ischium, it was tagged with a metallic marker. The marker used was a standard surgical ligaclip in all but one child, in whom small wire sutures were used. Care was taken thereafter not to markedly abduct the legs before cast immobilization, in an effort to minimize intra-operative loosening of the transferred tendon. Associated procedures were distal hamstring ‘releases’ in all 17 children and psoas tenotomy in 14 children. The releases involved lengthenings in 16 children and tenotomies in one child. After routine closure the child was immobilized in either a double-hip spica cast (15 children) (R.T.L. or D.D.A.) or bilateral long-leg cylinder casts with an abduction bar (two children) (c.L.L.). The average immobilization time was 5 - 7 (range 4 . 5 to 8.0) weeks. Physical therapy was instituted after cast removal. All children received abductor strengthening exercises and range of motion exercises for the hip and knee; gait training was administered to those children who were cruising, Hoffer-class non-functional or who were household ambulators (there were no community ambulators) (Hoffer et al. 1973). Anteroposterior radiographs of the pelvis were taken pre-operatively, immediately postoperatively (first or second day), at cast removal, and at three- to six-
month follow-up visits. The pre-operative and follow-up visit films were taken in a standard position: the patient was supine, with the hips and knees extended, the heels separated and the great toes approximated. This produced approximately I S ” of symmetrical internal rotation of both lower extremities. The tube was centered 4cm proximal to the pubic symphysis, with a tube-to-film distance of 100cm. The closest distance between the metallic marker and the ischial tuberosity was measured on the immediate postoperative and on all followup visit films. All measurements were made by an independent observer ( A . H . ) . An increase of > lOmm distance between the metallic marker and the ischium compared with the initial postoperative radiograph was considered to be significant and defined as ‘adductor pullout’ (an example is shown in Fig. 1). While reviewing consecutive radiographs where an obvious pull-out had occurred, the distance change was always > lOmm, and usually >20mm. Thus lOmm was arbitrarily defined and chosen to indicate adductor pull-out. The time of adductor pull-out was classified as peri-operative (noted on the first postoperative film), during cast immobilization (between the immediately postoperative film and cast removal), or after cast removal. Functional assessment was determined both pre-operatively and postoperatively. The ambulatory capability of each child was classified according to Hoffer et al. (1973). A numerical grade was assigned to each class for the purposes of analysis: grade 1, non-ambulators; grade 2, nonfunctional ambulators; grade 3, household ambulators; and grade 4, community ambulators (Aronson et al. 1991). It was possible to determine this functional grade for six of the seven quadriplegic and nine of the 10 diplegic children. For those who were ambulators, the pre- and postoperative notes recorded by the physicians and physical therapists were also reviewed. Although gait laboratory analysis of the ambulatory patients would have been ideal both pre- and postoperatively, we did not have access to a gait laboratory in our area, and certain patients would have been unable to travel the distances necessary to undergo gait
analysis at other centers. For these reasons we did not perform gait analysis.
Results The average follow-up was 1 year 7 months (range two to 24 months). One child with only two months follow-up was included because bilateral pull-out had already occurred. Of the 33 hips, the tendon remained in its new position in 19. In 11 hips the tendon definitely pulled away from the ischium, and in three the clip position was equivocal (i.e. prolonged pull-out versus gradual growth). Of the 1 1 hips with definite tendon pull-out, the average time of pull-out was six months postoperatively. The adductor tendons became detached during the perioperative period in two cases, during cast immobilization in one case and after cast removal in eight cases. Ischial pull-out was more common among children with spastic diplegia (nine of 20 hips) than those with spastic quadriplegia (two of 13 hips). There were 17 hips which did not experience pull-out and for which the preand postoperative ambulatory grades were known: the grade improved by one or more classes in six of these. There were 11 hips which did experience pull-out and for which the pre- and postoperative ambulatory grades were known; the grade improved by one or more classes in seven. The average pre-operative ambulatory grade was 1 for the spastic quadriplegic and 1.6 for the diplegic children; the average postoperative grades were 1.6 and 2.4, respectively. Physical therapy was instituted at an average of 2.3 months from the date of surgery for the quadriplegic and 2.6 months for the diplegic children. The average preoperative ambulatory grades for children's hips without and with ischial pull-out were 1.3 and 1-5, respectively; the postoperative grades .were 1 * 7 and 2.1. Physical therapy was instituted postoperatively at an average of 2 * 5 and 2.4 months, respectively, for those without and with ischial pull-out. The gait of ambulatory children who experienced pull-out was not discernibly different from those who did not experience pullout (either by the physicians or the physical therapists). Results for both
Fig. la. lmmediaie pre-operaiive radiograph of both hips of a male with spastic diplegia ai age 3 years 7 months. He underwent bilateral adductor transfers (adductor longus and gracilis), psoas tenotomies and disial medial hamstring lengthenings.
Fig. Ib. Radiograph of same paiieni at six hours postoperatively. Clip on patient's righi is slightly more disial than on left, inierpreied as tagging adductor longus iendon at differeni poinis rather than immediate pull-our (see Fig. Ic).
Fig. Ic. Final follow-up radiograph at I year 6 months after surgery: marked distal migration of clip on right hip and no change of lefi hip, inierpreted as compleie pull-out on right and no pu[~-ouion Iefi.
51
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TABLE I Patient summary
Spastic Spastic Total quadriplegia diplegia
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N children N hips Average age (yrs:mth5) Average cast time (wks) Ambulatory glade* Pre-operative Postoperative
Start of physical therapy (mths postop.) Average follow-up (yrs:mths) Resu I t s No pull-out Immediate postop. During cast immobilization After cast removal Equivocal
7 13
10
4:11
5%
17 33 5:3
5.6
5.7
5.7
I 1.6
1.6 1.9
1.3
2.3
2.6
2.5
2:0
1:4
1.7
9 I
10 1
19
0 1
I 7
2
1
20
1.8
2 1
8 3
* 1 = non-ambulator, 2 = non-functional ambulator, 3 =household ambulator, 4 = community ambulator.
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groups and the total are summarized in Table I.
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Discussion Posterior adductor tendon transfer was originally described by Perry. Her experience with it was in patients with poliomyelitis who required reinforcement of weakened hip extensors, and at her suggestion it was tried in children with cerebral palsy. Stephenson and Donovan (1969) were the first to report their results of adductor transfer in patients with cerebral palsy, and since then several authors have reported the procedure (Couch el al. 1977, Griffin et al. 1977, Baumann el al. 1978, Root and Spero 1981, Reimers and Poulsen 1984). Root and Spero, in a study comparing adductor transfer with tenotomy, concluded that the functional results were better for the transfer. However, Reimers and Poulsen felt there t o be no difference in hip stability when comparing the results of transfer and tenotomy. If indeed the posterior adductor transfer does have an advantage (improvement of hip extension), then it must remain at its new origin; if it does not, but rather pulls off, the transfer effectively becomes an adductor release.
In the present series we have shown that 11 of 33 posterior adductor transfers pulled away from the ischium. Root and Spero (1981) on clinical examination felt that the transferred adductors remained attached to their new ischial origin. However, Bleck (1987) has stated that in a few cases in which he tagged the transferred tendon the clip moved distally, therefore the transfer is essentially an adductor tenotomy and has no advantage. Interestingly, we found a higher rate of pull-out among children with spastic diplegia than among those with spastic quadriplegia. Because of their more severe neurological dysfunction and increased spasticity, one might expect it to be more common among spastic quadriplegic children. However, the majority of the pull-outs occurred after cast removal (eight of 11). We relate this to the diplegic children being more ambulatory than the quadriplegic children, both preoperatively (average ambulatory grade 1 '6, versus 1) and post-operatively (average ambulatory grade 2 . 4 versus 1.6). Ambulation increases the forces placed on the transferred adductors. The healing is probably not sufficient for development of Sharpey's fibers to withstand mechanically the stresses of weight-bearing and ambulation; this leads t o ischial pull-out. We do not feel that the pull-out was caused by physical therapy, since the time for therapy institution was similar for the diplegic and quadriplegic children (2.3 versus 2 - 6 months), and for those with or without ischial pull-out (2.4 versus 2.5 months). The question might also be raised regarding the type of cast immobilization and its influence on pull-out. Nearly all of the children in this study had the same cast immobilization: 15 in double-hip spicas, with only two in bilateral cylinder casts. Three of the four hips immobilized in bilateral cylinder casts and six of the 29 hips immobilized in double-hip spicas experienced ischial pull-out. However, the numbers in the bilateral cylinder group are too small to make any statistical inference regarding differences between these two groups. Aronson et al. (1991) noted no statistically significant clinical difference in a recent review (where the
transferred adductor longus tendon was not tagged) between those immobilized in bilateral cylinder casts with a crossbar for four weeks and those in a double-hip spica cast for six weeks. We conclude from this study that approximately one-third of children with spastic cerebral palsy undergoing posterior adductor transfer will experience ischial pull-out. However, the transferred tendon seems to remain at its new origin in at least half of the children. Whether the functional results of a twothirds success rate for posterior adductor transfer is better than that for simple tenotomy remains t o be seen; clinically we could see no discernible difference in gait. As Bleck (1990) has stated, this remains to be studied with the technology of gait analysis that is now available. Griffin et af. (1977), on the basis of gait analysis in six patients undergoing adductor transfer, felt that the gait was less broadly based, with less trunk shift, more security, and a longer single support-phase in stance. However, in our children gait analysis
would not be so valuable as a pure test of postoperative adductor function, since all but three underwent psoas tenotomy and all underwent distal hamstring surgery.
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Accepted for publication 19th September 1991
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Ackno wledgetnents The authors wish to acknowledge the advice and constructive criticism of Robert N. Hensinger, M.D., in preparation of this manuscript, as well as the secretarial assistance of Lisa Janovits. This paper was presented at the 44th Annual Meeting of the American Academy for Cerebral Palsy and Developmental Medicine, October 3-6, 1990, Orlando, Florida.
2
3
Authors’ Appointments Randall T. Loder, M.D., Assistant Professor of Orthopaedics (now Assistant Professor of Surgery, University of Michigan, Ann Abor, MI); Alan Harbuz, B.S., Senior Medical Student; David D. Aronson, M.D., Assistant Professor of Orthopaedics (now Associate Professor of Orthopaedics, University of Vermont, Burlington, Vermont); Christopher L. Lee, M.D., Clinical Assistant Professor of Orthopaedics; Wayne State University, Detroit, MI. Correspondence to first author at Section of Orthopaedic Surgery, 1500 E. Medical Center Drive, 2912K Taubman Center, Box 0328, University of Michigan, Ann Arbor, MI 48109-0328.
SUMMARY The adductor longus tendon was tagged with metallic markers after posterior adductor transfer in 17 children (33 hips) with cerebral palsy: 10 had spastic diplegia and seven had spastic quadriplegia. The average age at operation was 5 years 3 months, time of postoperative immobilization 5 . 7 weeks and average follow-up 1 year 7 months. In 19 hips the tendon remained attached to the ischium, in 11 hips it pulled away from the ischium and in three hips the result was equivocal. The incidence of detachment was higher among diplegic children than quadriplegic children. RESUME Migration post operatoire du tendon adducteur apres transfert du grand adducteur chez I’enfant I.M.C. Le tendon adducteur a ete marque par des etiquettes metalliques apres transfert du grand adducteur chez 17 enfants I.M.C. (33 hanches): 10 presentaient une diplegie spastique et sept une quadriplegie spastique. L’Bge moyen a I’intervention etait de 5 ans 3 mois, le delai d’immobilisation postoperatoire de 5,7 semaines el le suivi rnoyen d’un an sept mois. Le tendon restait fixe a I’ischion pour 19 hanches, il s’en etait dttache pour 11 hanches et le resultat etait douteux pour trois hanches. L’incidence d e la desinsertion etait plus devee en cas d e diplegie qu’en cas d e quadriplegie. ZUSAMMENFASSUNG Postoperative Wanderung der Adduktorsehne nach posteriorer Verlagerung des Adduktor bei Kindern mil Cerebralparese Bei 17 Kindern (33 Hiiften) mit Cerebralparese, von denen 10 eine spastische Diplegie und sieben eine spastische Tetraplegie hatten, wurde, nach posteriorer Verlagerung des Adduktor longus, die Sehne des Adduktor rnit metallischen Markern versehen. Das Durchschnittsalter bei der Operation war funf Jahre und drei Monate, die postoperative Irnmobilisation betrug 5 . 7 Wochen und die durchschnittliche Nachuntersuchungszeit ein Jahr und sieben Monate. Bei 19 Hiiften blieb die Sehne am Sitzbein, bei 1 1 Hiiften loste sie sich vom Sitzbein und bei drei Hiiften war das Ergebnis zweifelhaft. Bei den Kindern mit Diplegie kam as haufiger zu einer Ablosung als bei den Kindern mit Tetraplegie. RESUMEN Migracion postoperatoria del tendon del aductor despues del trasplante del aductor posterior en niiios con paralisis cerebral El tendon largo del aductor fue marcado con marcadores metalicos despues del trasplante del aductor posterior en 17 niiros (33 caderas) con paralisis cerebral: 10 tenian diplejia espastica y siete
53
i
.
cuadriplejia espastica. El promedio d e edad en la operacion era d e 5 aiios y 3 meses, el periodo d e inmovilizacion postoperatoria de 5, 7 semanas y el periodo de seguimiemto de I aiio y 7 mrses. En 19 caderas el tendon permanecia adherido al isquion. En 1 1 caderas empujaba hacia afuera del isquion y en tres caderas el resultado fue equivoco. La incidencia d e desinsercion era mayor en 10s niiios diplejicos que en 10s cuadriplejicos.
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References Aronson, D. D., Zak, P. J . , Lee, C. L., Bollinger, R . 0.. LaMont. R. L. (1991) ‘Posterior transfer of the adductors in children who have cerebral palsy: a long-term study.’ Journal of Bone and Joint Surgery, 13A, 59-65. Banks, H. H . , Green, W. T. (1960) ‘Adductor myotomy and obturator neurectomy for correction of adduction contracture of the hip in cerebral palsy.’ Journal of Bone and Joint Surgery, 42A, 1 1 1-126. Baumann, J . U., Meyer, E., Schurmann, K . (1978) ‘Hip adductor transfer to the ischial tuberosity in spastic and paralytic hip disorders.’ Archives of Orthopaedic Traumatology and Surgery, 92, 107-1 12. Bleck, E. E. (1987) Orthopaedic Management in Cerebral Palsy. Clinics in Developmental Medicine, Nos. 99-100. London: Mac Keith Press with Blackwell Scientific; Philadelphia: Lippincott. - (1990) ‘Current concepts review. Management of the lower extremities in children who have cerebral palsy.’ Journal of Bone and Joint Surgery, 72.4, 140-144. Couch, W . H., Jr., DeRosa, G. P., Throop, F. B. (1977) ‘Thigh adductor transfer for spastic cerebral palsy.’ Developmental Medicine and Child Neurology, 19, 343-349. Griffin, P . P., Wheelhouse, W. W., Shiavi, R. (1977) ‘Adductor transfer for adductor spasticity: clinical and electromyographic gait analysis.’ Developmental Medicine and Child Neurology,
19, 783-789. Hoffer, M. M., Feiwell, E., Perry, R., Perry, J . , Bonnett, C . (1973) ‘Functional ambulation in patients with myelomeningocele.’ Journal of Bone and Joint Surgery, 55.4, 137-148. Keats, S. (1957) ‘Combined adductor-gracilis tenotomy and selective obturator nerve resection for the correction of adduction deformity of the hip in children with cerebral palsy.’ Journal of Bone and Joint Surgery, 39A, 1087-1090. Matsuo, T., Tada, S., Hajime, T . (1986) ‘Insufficiency of the hip adductor after anterior obturator neurectomy in 42 children with cerebral palsy.’ Journal of Pediairic Orihopedics, 6 , 686-692. Reimers, J., Poulsen, S. (1984) ‘Adductor transfer versus tenotomy for stability of the hip in spastic cerebral palsy.’ Journal of Pediatric Orthopedics, 4, 52-54. Root, L., Spero, C. R. (1981) ‘Hip adductor transfer compared with adductor tenotomy in cerebral palsy.’ Journal of Bone and Joini Surgery, 63A, 767-772. Samilson, R. L., Carson, J . J., Preston, J . , Raney, F. L. (1967) ‘Results and complications of adductor tenotomy and obturator neurectomy in cerebral palsy.’ Clinical Orthopaedics and Related Research, 54, 61-73. Stephenson, C . T., Donovan, M. M. (1969) ‘Transfer of hip adductor origins to the ischium in spastic cerebral palsy.’ Journal of Bone and Joint Surgery, 51.4, 1050. (Abstract.)
A common hip deformity of children with spastic cerebral palsy is an adduction contracture (Banks and Green 1960, Samilson et al. 1967, Root and Spero 1981). Before severe hip subluxation has developed, soft-tissue procedures alone can improve the contractures and decrease the scissoring gait pattern, and often can improve the hip subluxation when mild. The two most common softtissue procedures are adductor tenotomy, with or without anterior branch obturator neurectomy (Keats 1957, Banks and Green 1960, Matsuo et al. 1986), and posterior transfer of the adductor longus and gracilis tendons to the ischiurn, with or without the adductor brevis and magnus (Stephenson and Donovan 1969, Baumann et al. 1978, Root and Spero 1981, Reimers and Paulsen 1984, Aronson et al. 1991). Although the transfer usually requires a longer operative time and is technically more difficult, several authors feel it is a better procedure (Couch et al. 1977, Baumann et al. 1978, Matsuo et al. 1986), imparting some hip extension and reducing the risk of overcorrection or creation of an abduction contracture (Samilson et al. 1967, Griffin el a/. 1977, Matsuo et al. 1986). Aronson et al. (1991), in a recent review of the posterior adductor transfer, generally found satisfactory results, with the transfer doing better in children with spastic diplegia
than with spastic quadriplegia. However, the question arose as to whether the newly transferred tendon remains attached to the ischium. If it pulls away, then in essence the transfer becomes an adductor tenotomy. T o answer this question we undertook a review of children undergoing adductor transfer, in which the newly transferred tendons had been tagged with metallic markers and followed over time.
Material and method
Three staff orthopaedists at the Detroit Institute for Children (outpatient unit) and the Children's Hospital of Michigan (inpatient unit), (Detroit, MI), began personally to follow their own adductor transfers by tagging the adductor longus tendon. 17 children (eight boys and nine girls) with spastic cerebral palsy who had undergone posterior adductor transfers on 33 hips comprised the study group. Seven children had spastic quadriplegia and 10 had spastic diplegia. The average age at surgery was 5 years 3 months (range 1 year 9 months t o 15 years 10 months), 4 years 11 months for the spastic quadriplegic children and 5 years 9 months for the spastic diplegic children. The surgical technique of the posterior adductor transfer, as described by Root and Spero (1981), was used. The operative procedure was performed through a groin incision, beginning at the origin of the
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adductor longus and extending 8cm toward the ischial tuberosity. The origins of the adductor longus and gracilis were removed subperiosteally and transferred posteriorly. They were sutured directly to the ischial tuberosity and/or its periosteum, using 0-size non-absorbable sutures (coated polyester, e.g. ‘Ethibond’). The sutures were anchored directly into the ischial tuberosity using a very sturdy, sharp-pointed needle. In younger children, the ischiopubic junction is cartilagenous and in this circumstance the suturing is easier by direct suture into cartilage. If the suture could not be passed through the ischial tuberosity proper (e.g. too hard for needle passage) its periosteum or perichondrium was used. The origins of the adductor brevis and anterior portion of the adductor magnus were released (myotomy). Obturator neurectomy was not performed. After the adductor longus tendon transfer had been sutured into the ischium, it was tagged with a metallic marker. The marker used was a standard surgical ligaclip in all but one child, in whom small wire sutures were used. Care was taken thereafter not to markedly abduct the legs before cast immobilization, in an effort to minimize intra-operative loosening of the transferred tendon. Associated procedures were distal hamstring ‘releases’ in all 17 children and psoas tenotomy in 14 children. The releases involved lengthenings in 16 children and tenotomies in one child. After routine closure the child was immobilized in either a double-hip spica cast (15 children) (R.T.L. or D.D.A.) or bilateral long-leg cylinder casts with an abduction bar (two children) (c.L.L.). The average immobilization time was 5 - 7 (range 4 . 5 to 8.0) weeks. Physical therapy was instituted after cast removal. All children received abductor strengthening exercises and range of motion exercises for the hip and knee; gait training was administered to those children who were cruising, Hoffer-class non-functional or who were household ambulators (there were no community ambulators) (Hoffer et al. 1973). Anteroposterior radiographs of the pelvis were taken pre-operatively, immediately postoperatively (first or second day), at cast removal, and at three- to six-
month follow-up visits. The pre-operative and follow-up visit films were taken in a standard position: the patient was supine, with the hips and knees extended, the heels separated and the great toes approximated. This produced approximately I S ” of symmetrical internal rotation of both lower extremities. The tube was centered 4cm proximal to the pubic symphysis, with a tube-to-film distance of 100cm. The closest distance between the metallic marker and the ischial tuberosity was measured on the immediate postoperative and on all followup visit films. All measurements were made by an independent observer ( A . H . ) . An increase of > lOmm distance between the metallic marker and the ischium compared with the initial postoperative radiograph was considered to be significant and defined as ‘adductor pullout’ (an example is shown in Fig. 1). While reviewing consecutive radiographs where an obvious pull-out had occurred, the distance change was always > lOmm, and usually >20mm. Thus lOmm was arbitrarily defined and chosen to indicate adductor pull-out. The time of adductor pull-out was classified as peri-operative (noted on the first postoperative film), during cast immobilization (between the immediately postoperative film and cast removal), or after cast removal. Functional assessment was determined both pre-operatively and postoperatively. The ambulatory capability of each child was classified according to Hoffer et al. (1973). A numerical grade was assigned to each class for the purposes of analysis: grade 1, non-ambulators; grade 2, nonfunctional ambulators; grade 3, household ambulators; and grade 4, community ambulators (Aronson et al. 1991). It was possible to determine this functional grade for six of the seven quadriplegic and nine of the 10 diplegic children. For those who were ambulators, the pre- and postoperative notes recorded by the physicians and physical therapists were also reviewed. Although gait laboratory analysis of the ambulatory patients would have been ideal both pre- and postoperatively, we did not have access to a gait laboratory in our area, and certain patients would have been unable to travel the distances necessary to undergo gait
analysis at other centers. For these reasons we did not perform gait analysis.
Results The average follow-up was 1 year 7 months (range two to 24 months). One child with only two months follow-up was included because bilateral pull-out had already occurred. Of the 33 hips, the tendon remained in its new position in 19. In 11 hips the tendon definitely pulled away from the ischium, and in three the clip position was equivocal (i.e. prolonged pull-out versus gradual growth). Of the 1 1 hips with definite tendon pull-out, the average time of pull-out was six months postoperatively. The adductor tendons became detached during the perioperative period in two cases, during cast immobilization in one case and after cast removal in eight cases. Ischial pull-out was more common among children with spastic diplegia (nine of 20 hips) than those with spastic quadriplegia (two of 13 hips). There were 17 hips which did not experience pull-out and for which the preand postoperative ambulatory grades were known: the grade improved by one or more classes in six of these. There were 11 hips which did experience pull-out and for which the pre- and postoperative ambulatory grades were known; the grade improved by one or more classes in seven. The average pre-operative ambulatory grade was 1 for the spastic quadriplegic and 1.6 for the diplegic children; the average postoperative grades were 1.6 and 2.4, respectively. Physical therapy was instituted at an average of 2.3 months from the date of surgery for the quadriplegic and 2.6 months for the diplegic children. The average preoperative ambulatory grades for children's hips without and with ischial pull-out were 1.3 and 1-5, respectively; the postoperative grades .were 1 * 7 and 2.1. Physical therapy was instituted postoperatively at an average of 2 * 5 and 2.4 months, respectively, for those without and with ischial pull-out. The gait of ambulatory children who experienced pull-out was not discernibly different from those who did not experience pullout (either by the physicians or the physical therapists). Results for both
Fig. la. lmmediaie pre-operaiive radiograph of both hips of a male with spastic diplegia ai age 3 years 7 months. He underwent bilateral adductor transfers (adductor longus and gracilis), psoas tenotomies and disial medial hamstring lengthenings.
Fig. Ib. Radiograph of same paiieni at six hours postoperatively. Clip on patient's righi is slightly more disial than on left, inierpreied as tagging adductor longus iendon at differeni poinis rather than immediate pull-our (see Fig. Ic).
Fig. Ic. Final follow-up radiograph at I year 6 months after surgery: marked distal migration of clip on right hip and no change of lefi hip, inierpreted as compleie pull-out on right and no pu[~-ouion Iefi.
51
i
D L
TABLE I Patient summary
Spastic Spastic Total quadriplegia diplegia
h;
L
W
c YI
C
+2
z
d
U
-0
U
d
.-z
L
CJ c
b a L
c
L
0 I
U
N children N hips Average age (yrs:mth5) Average cast time (wks) Ambulatory glade* Pre-operative Postoperative
Start of physical therapy (mths postop.) Average follow-up (yrs:mths) Resu I t s No pull-out Immediate postop. During cast immobilization After cast removal Equivocal
7 13
10
4:11
5%
17 33 5:3
5.6
5.7
5.7
I 1.6
1.6 1.9
1.3
2.3
2.6
2.5
2:0
1:4
1.7
9 I
10 1
19
0 1
I 7
2
1
20
1.8
2 1
8 3
* 1 = non-ambulator, 2 = non-functional ambulator, 3 =household ambulator, 4 = community ambulator.
-0
U
d
CJ
5 L
0
groups and the total are summarized in Table I.
C
.-
I
.200
z 0
.-
I
2 I
Y)
0
a
52
Discussion Posterior adductor tendon transfer was originally described by Perry. Her experience with it was in patients with poliomyelitis who required reinforcement of weakened hip extensors, and at her suggestion it was tried in children with cerebral palsy. Stephenson and Donovan (1969) were the first to report their results of adductor transfer in patients with cerebral palsy, and since then several authors have reported the procedure (Couch el al. 1977, Griffin et al. 1977, Baumann el al. 1978, Root and Spero 1981, Reimers and Poulsen 1984). Root and Spero, in a study comparing adductor transfer with tenotomy, concluded that the functional results were better for the transfer. However, Reimers and Poulsen felt there t o be no difference in hip stability when comparing the results of transfer and tenotomy. If indeed the posterior adductor transfer does have an advantage (improvement of hip extension), then it must remain at its new origin; if it does not, but rather pulls off, the transfer effectively becomes an adductor release.
In the present series we have shown that 11 of 33 posterior adductor transfers pulled away from the ischium. Root and Spero (1981) on clinical examination felt that the transferred adductors remained attached to their new ischial origin. However, Bleck (1987) has stated that in a few cases in which he tagged the transferred tendon the clip moved distally, therefore the transfer is essentially an adductor tenotomy and has no advantage. Interestingly, we found a higher rate of pull-out among children with spastic diplegia than among those with spastic quadriplegia. Because of their more severe neurological dysfunction and increased spasticity, one might expect it to be more common among spastic quadriplegic children. However, the majority of the pull-outs occurred after cast removal (eight of 11). We relate this to the diplegic children being more ambulatory than the quadriplegic children, both preoperatively (average ambulatory grade 1 '6, versus 1) and post-operatively (average ambulatory grade 2 . 4 versus 1.6). Ambulation increases the forces placed on the transferred adductors. The healing is probably not sufficient for development of Sharpey's fibers to withstand mechanically the stresses of weight-bearing and ambulation; this leads t o ischial pull-out. We do not feel that the pull-out was caused by physical therapy, since the time for therapy institution was similar for the diplegic and quadriplegic children (2.3 versus 2 - 6 months), and for those with or without ischial pull-out (2.4 versus 2.5 months). The question might also be raised regarding the type of cast immobilization and its influence on pull-out. Nearly all of the children in this study had the same cast immobilization: 15 in double-hip spicas, with only two in bilateral cylinder casts. Three of the four hips immobilized in bilateral cylinder casts and six of the 29 hips immobilized in double-hip spicas experienced ischial pull-out. However, the numbers in the bilateral cylinder group are too small to make any statistical inference regarding differences between these two groups. Aronson et al. (1991) noted no statistically significant clinical difference in a recent review (where the
transferred adductor longus tendon was not tagged) between those immobilized in bilateral cylinder casts with a crossbar for four weeks and those in a double-hip spica cast for six weeks. We conclude from this study that approximately one-third of children with spastic cerebral palsy undergoing posterior adductor transfer will experience ischial pull-out. However, the transferred tendon seems to remain at its new origin in at least half of the children. Whether the functional results of a twothirds success rate for posterior adductor transfer is better than that for simple tenotomy remains t o be seen; clinically we could see no discernible difference in gait. As Bleck (1990) has stated, this remains to be studied with the technology of gait analysis that is now available. Griffin et af. (1977), on the basis of gait analysis in six patients undergoing adductor transfer, felt that the gait was less broadly based, with less trunk shift, more security, and a longer single support-phase in stance. However, in our children gait analysis
would not be so valuable as a pure test of postoperative adductor function, since all but three underwent psoas tenotomy and all underwent distal hamstring surgery.
s d m d”
m
m m-
Accepted for publication 19th September 1991
Q‘
Ackno wledgetnents The authors wish to acknowledge the advice and constructive criticism of Robert N. Hensinger, M.D., in preparation of this manuscript, as well as the secretarial assistance of Lisa Janovits. This paper was presented at the 44th Annual Meeting of the American Academy for Cerebral Palsy and Developmental Medicine, October 3-6, 1990, Orlando, Florida.
2
3
Authors’ Appointments Randall T. Loder, M.D., Assistant Professor of Orthopaedics (now Assistant Professor of Surgery, University of Michigan, Ann Abor, MI); Alan Harbuz, B.S., Senior Medical Student; David D. Aronson, M.D., Assistant Professor of Orthopaedics (now Associate Professor of Orthopaedics, University of Vermont, Burlington, Vermont); Christopher L. Lee, M.D., Clinical Assistant Professor of Orthopaedics; Wayne State University, Detroit, MI. Correspondence to first author at Section of Orthopaedic Surgery, 1500 E. Medical Center Drive, 2912K Taubman Center, Box 0328, University of Michigan, Ann Arbor, MI 48109-0328.
SUMMARY The adductor longus tendon was tagged with metallic markers after posterior adductor transfer in 17 children (33 hips) with cerebral palsy: 10 had spastic diplegia and seven had spastic quadriplegia. The average age at operation was 5 years 3 months, time of postoperative immobilization 5 . 7 weeks and average follow-up 1 year 7 months. In 19 hips the tendon remained attached to the ischium, in 11 hips it pulled away from the ischium and in three hips the result was equivocal. The incidence of detachment was higher among diplegic children than quadriplegic children. RESUME Migration post operatoire du tendon adducteur apres transfert du grand adducteur chez I’enfant I.M.C. Le tendon adducteur a ete marque par des etiquettes metalliques apres transfert du grand adducteur chez 17 enfants I.M.C. (33 hanches): 10 presentaient une diplegie spastique et sept une quadriplegie spastique. L’Bge moyen a I’intervention etait de 5 ans 3 mois, le delai d’immobilisation postoperatoire de 5,7 semaines el le suivi rnoyen d’un an sept mois. Le tendon restait fixe a I’ischion pour 19 hanches, il s’en etait dttache pour 11 hanches et le resultat etait douteux pour trois hanches. L’incidence d e la desinsertion etait plus devee en cas d e diplegie qu’en cas d e quadriplegie. ZUSAMMENFASSUNG Postoperative Wanderung der Adduktorsehne nach posteriorer Verlagerung des Adduktor bei Kindern mil Cerebralparese Bei 17 Kindern (33 Hiiften) mit Cerebralparese, von denen 10 eine spastische Diplegie und sieben eine spastische Tetraplegie hatten, wurde, nach posteriorer Verlagerung des Adduktor longus, die Sehne des Adduktor rnit metallischen Markern versehen. Das Durchschnittsalter bei der Operation war funf Jahre und drei Monate, die postoperative Irnmobilisation betrug 5 . 7 Wochen und die durchschnittliche Nachuntersuchungszeit ein Jahr und sieben Monate. Bei 19 Hiiften blieb die Sehne am Sitzbein, bei 1 1 Hiiften loste sie sich vom Sitzbein und bei drei Hiiften war das Ergebnis zweifelhaft. Bei den Kindern mit Diplegie kam as haufiger zu einer Ablosung als bei den Kindern mit Tetraplegie. RESUMEN Migracion postoperatoria del tendon del aductor despues del trasplante del aductor posterior en niiios con paralisis cerebral El tendon largo del aductor fue marcado con marcadores metalicos despues del trasplante del aductor posterior en 17 niiros (33 caderas) con paralisis cerebral: 10 tenian diplejia espastica y siete
53
i
.
cuadriplejia espastica. El promedio d e edad en la operacion era d e 5 aiios y 3 meses, el periodo d e inmovilizacion postoperatoria de 5, 7 semanas y el periodo de seguimiemto de I aiio y 7 mrses. En 19 caderas el tendon permanecia adherido al isquion. En 1 1 caderas empujaba hacia afuera del isquion y en tres caderas el resultado fue equivoco. La incidencia d e desinsercion era mayor en 10s niiios diplejicos que en 10s cuadriplejicos.
t-;
b
. 4
U
1
U
U
Q
.-b L
W
c
s
a L.
d C U
C
G
0
5 L
0
54
References Aronson, D. D., Zak, P. J . , Lee, C. L., Bollinger, R . 0.. LaMont. R. L. (1991) ‘Posterior transfer of the adductors in children who have cerebral palsy: a long-term study.’ Journal of Bone and Joint Surgery, 13A, 59-65. Banks, H. H . , Green, W. T. (1960) ‘Adductor myotomy and obturator neurectomy for correction of adduction contracture of the hip in cerebral palsy.’ Journal of Bone and Joint Surgery, 42A, 1 1 1-126. Baumann, J . U., Meyer, E., Schurmann, K . (1978) ‘Hip adductor transfer to the ischial tuberosity in spastic and paralytic hip disorders.’ Archives of Orthopaedic Traumatology and Surgery, 92, 107-1 12. Bleck, E. E. (1987) Orthopaedic Management in Cerebral Palsy. Clinics in Developmental Medicine, Nos. 99-100. London: Mac Keith Press with Blackwell Scientific; Philadelphia: Lippincott. - (1990) ‘Current concepts review. Management of the lower extremities in children who have cerebral palsy.’ Journal of Bone and Joint Surgery, 72.4, 140-144. Couch, W . H., Jr., DeRosa, G. P., Throop, F. B. (1977) ‘Thigh adductor transfer for spastic cerebral palsy.’ Developmental Medicine and Child Neurology, 19, 343-349. Griffin, P . P., Wheelhouse, W. W., Shiavi, R. (1977) ‘Adductor transfer for adductor spasticity: clinical and electromyographic gait analysis.’ Developmental Medicine and Child Neurology,
19, 783-789. Hoffer, M. M., Feiwell, E., Perry, R., Perry, J . , Bonnett, C . (1973) ‘Functional ambulation in patients with myelomeningocele.’ Journal of Bone and Joint Surgery, 55.4, 137-148. Keats, S. (1957) ‘Combined adductor-gracilis tenotomy and selective obturator nerve resection for the correction of adduction deformity of the hip in children with cerebral palsy.’ Journal of Bone and Joint Surgery, 39A, 1087-1090. Matsuo, T., Tada, S., Hajime, T . (1986) ‘Insufficiency of the hip adductor after anterior obturator neurectomy in 42 children with cerebral palsy.’ Journal of Pediairic Orihopedics, 6 , 686-692. Reimers, J., Poulsen, S. (1984) ‘Adductor transfer versus tenotomy for stability of the hip in spastic cerebral palsy.’ Journal of Pediatric Orthopedics, 4, 52-54. Root, L., Spero, C. R. (1981) ‘Hip adductor transfer compared with adductor tenotomy in cerebral palsy.’ Journal of Bone and Joini Surgery, 63A, 767-772. Samilson, R. L., Carson, J . J., Preston, J . , Raney, F. L. (1967) ‘Results and complications of adductor tenotomy and obturator neurectomy in cerebral palsy.’ Clinical Orthopaedics and Related Research, 54, 61-73. Stephenson, C . T., Donovan, M. M. (1969) ‘Transfer of hip adductor origins to the ischium in spastic cerebral palsy.’ Journal of Bone and Joint Surgery, 51.4, 1050. (Abstract.)
