Develop. Med. Child Neurol. 1977, 19, 343-349
Thigh Adductor Transfer for Spastic Cerebral Palsy William H. Couch, Jr. G. Paul DeRosa Frank B. Throop
Introduction The child with cerebral palsy often displays a gait characterized by flexion, adduction and internal rotation of the thighs, with flexion at the knees. Many authors have attributed the flexed and adducted position of the thigh to spasticity of the thigh flexor and adductor muscles. However, the muscles responsible for the internal rotation deformity have been the subject of much controversy. Most anatomists agree that the tensor fascia lata and the anterior one-third of the gluteus minimus and medius act as internal rotators of the thigh at the hip. With increasing flexion, the function of internal rotation is enhanced. The adductor musculature has an obvious function in flexion and adduction, but its rotatory function is controversial. Hollinshead (1969) ascribes internal rotation function to the gracilis and the posterior portion of the adductor magnus, but admits that there is disagreement as to the rotatory function of the adductor longus and brevis. Brunnstrom (1966) states that the function of the adductor brevis and longus may be either internal or external rotation, depending upon the position of the thigh
in relation to the trunk. He further notes that one may palpate contraction of the adductors when the patient is asked to voluntarily internally rotate the thigh, but not feel such contraction upon voluntary external rotation. Frost (1971) has noted the previously-mentioned flexion, adduction and internal rotation of the hip and has aptly called it ‘the spastic crouch’. He feels that in the position of flexion and adduction the adductor muscles primarily produce an internal rotatory force. Various surgical procedures have been formulated and carried out in an effort to decrease the internal rotatory position in the spastic crouch. Durham (1938) describes a procedure for the relief of internal rotation of the thigh in spastic paralysis which involves sectioning the tensor fascia lata and the anterior one-third of the gluteus medius and minimus muscles. He claimed good results in all the procedures he performed. Barr (1943) reported a procedure for the correction of spastic internal rotation and flexion of the thigh by means of posterior transfer of the origins of the tensor fascia lata and the anterior one-third of the gluteus medius and minimus muscle mass. He noted,
Correspondence to William H. Couch, Jr., M.D., Staff Orthopedic Surgeon, United States Airforce Hospital, Clark Air Base, Republic of the Philippines.
343
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1977, 19
thighs, the operative field is draped. The surgeon sits facing the legs and begins a skin incision just superior to the taut tendon of the adductor longus and extends it posteriorly in a straight line to the ischial tuberosity, as nearly as possible in parallel to the borders of the pubic ramus and ischium. After the skin and subcutaneous tissues are divided, selfretaining retractors may be used to facilitate exposure. The tendon of the adductor longus is identified and a heavy tag suture is placed through its tendinous origin. Using electrocautery, the tendon is then severed from its origin on the pubic ramus. The origins of the adductor brevis, gracilis and anterior portions of the adductor magnus are released with electrocautery, making sure to stay directly next to the bone from which they arise. The end-point for this dissection is the inner surface of the obturator foramen and the shining fascia1 structure of the obturator externus. It is usually found that for the adductor longus tendon to reach the ischial tuberosity, the thigh must be extended and adducted. To accomplish this, an assistant cuts the tape from the pelvic stirrup and straightens the leg-holder to extend and adduct the thigh. An incision is then made into the apophysis of the ischial tuberosity. The adductor brevis, magnus and gracilis are pushed posteriorly toward the ischial tuberosity and rolled under the tendon of the adductor longus. By means of softtissue dissection the adductor longus is freed distally from the thigh, placed in a straight line and secured by several nonabsorbable sutures directly into the apophysis of the ischium. The wound is then thoroughly irrigated, the subcutaneous tissue is approximated and the skin closed with an absorbable synthetic suture. The wounds are then sealed with a topical plastic aerosol dressing. The opposite side is then completed in a similar fashion, but
however, that this was primarily for flexion and internal rotation deformities, and if adductor tightness was a significant problem he recommended a simultaneous or prior release of the adductor origin. Green and McDermott (1942) and Banks and Green (1960) described the technique and results of adductor myotomy and anterior branch obturator neurectomy. Initially, Green and McDermott reported a significant number of poor results, which they attributed to recurrence of deformity secondary to insufficient length of immobilization. Later, Banks and Green appeared to be more pleased with the procedure and reported that no child was made worse by it and that hip subluxation and recent dislocations were significantly decreased. The procedure known as adductor transfer was first accomplished in 1955 by Garrett at the Rancho Los Amigos Hospital (Nickel et al. 1966, Nickel 1974) for paralytic dislocation of the hip. The procedure described in the present article has been performed on cerebral-palsied children over the last 10 years at the Shriner’s Hospital for Crippled Children in Houston, Texas (Donovan 1974). Basically, it consists of the transfer of the origin of the adductor longus and gracilis posteriorly to the ischium, with release of the origins of the adductor brevis and the anterior portion of the adductor magnus.
Procedure Under general anesthesia, the patient is placed in the lithotomy position, with the buttocks resting on the end of the operating table. The legs are positioned with pelvic stirrups, and three-inch wide tape is placed just proximally to the knee and attached to the upright of the pelvic stirrup to hold the knee and thighs abducted as far as the tissues will permit. After thorough surgical preparation, including the entire perineum, buttocks, lower abdomen and proximal 344
WILLIAM H. COUCH, JR.
G. PAUL DEROSA
FRANK B. THROOP
of 30 months. Pre-operative movie-film and adequate records were available for all 32 patients at the time of follow-up, but in four cases the films were inadequate to provide the comparison needed for evaluation of post-operative results.
as the leg is extended and adducted it becomes necessary for the surgeon to stand to the side of the patient in order to suture the adductor longus tendon on the second side. The child is placed into long leg-braces with a pelvic band while still on the operating table and is kept in the braces and band for the first four post-operative weeks. During the first two weeks the hip and knee locks are released occasionally for comfort and to allow the child to assume a position of approximately 45" of flexion at the hips while eating. During the second week, active and passive range of motion are begun at the hips and knees while in the braces. Using braces instead of spica casts has prevented the problem of cast sores in these spastic children. The parents are instructed during the child's stay in the hospital to watch carefully for areas of skin pressure, particularly over the heels. All surgical procedures have been performed by the resident house-staff under attending supervision. The average operating time for the bilateral procedure was 1 hour 10 minutes, with a range of 45 minutes to 1 hour 40 minutes. The average blood-loss was ~OCC, with a range of 20 to 200cc. In no case was blood transfusion required. Complications were two superficial wound infections and one case of bilateral heel sores, all of which healed without sequelae after local treatment.
Results Five objective and two subjective criteria were used to evaluate each child at follow-up. The five objective criteria were: (1) width of base of gait; (2) combined abduction of the thighs in flexion; (3) rotation of the knees while walking; (4) rotation of the feet while walking; and (5) change in walking ability within six months of operation. Subjectivedeterminations were: (I) the examiner's opinion of the change in a child's over-all gait by comparing the pre-operative movie-film with the post-operative examination; and (2) the subjective opinion of each child's parents as to the effectiveness of the procedure on the child as a whole. Of the 28 children for whom adequate pre-operative movie-film was available, the width of base of gait was increased in 26, was unchanged in one and slightly decreased in another. The average preoperative base of gait was 13.5cm (range - 15 to +28cm); post-operatively the average had increased to 24cm (range 12 to 37cm). Combined adduction of the thighs in flexion increased in all patients. Preoperatively the average combined abduction was 50" (range 30" to 70"); post-operatively this had increased to an average of 110", with a range of 60" to 160". Pre-operatively, 24 patients displayed internal rotation at the knees while walking, four displayed neutral rotation and none had external rotation. Postoperatively, five patients persisted with internal rotation, 19 showed neutral
FO~~OW-UP Between December 1970 and January 1974, 35 patients underwent bilateral adductor transfer. 32 of the 35 children were available for follow-up and were examined personally. Their ages ranged from 3 years 6 months to 16 years 4 months (mean 7 years 7 months). The postoperative periods at follow-up ranged from 14 months to 51 months, with a mean 345
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
rotation and four had developed external rotation of the knees while walking. Rotation of the feet during walking, while not a direct function of internal rotation of the thigh, showed similar improvement. 21 patients had an in-toed gait pre-operatively, four had neutral rotation and three had out-toed gait. At follow-up eight patients retained an intoed gait, nine had achieved a neutral position and 11 had developed an out-toed gait. Walking ability pre- and post-operatively was evaluated in all 32 patients. Before surgery 12 of the 32 were non-ambulatory. Of the other 20 children, nine used various braces and crutches as aids in walking. Any change in walking ability that had occurred within six months of surgery was judged to be a beneficial result of the procedure, rather than simply normal maturation. Post-operatively all 32 patients were walking. Of the 12 children who had been non-ambulatory before surgery, six were walking unassisted and six were using external aids at follow-up. The 11 children who had been walking unassisted pre-operatively continued to do so. Of the nine children who had been walking with external aids pre-operatively, three were able to walk unassisted at follow-up, three had decreased their needs for external aids and the remaining three continued to walk with the same aids they had used pre-operatively. The object of the operation was to improve the functional and ambulatory ability of the child as a whole, and to improve the cosmetic appearance of the patient’s gait. Judging from the 28 preoperative movie-films that were adequate, the examiner’s opinion was that all 28 patients showed an improvement in gait and functional ability. The 32 parents were asked to assess the value of the operation for their child: 31 said that it had helped and only one
1977, 19
parent felt that the child was worse as a result. Rating of Post-operative Improvement
An arbitrary rating system was devised to grade the results of the procedure, based on the above criteria. Two points were awarded for an improvement in each criterion, one point for no change and zero if the child was worse compared with the pre-operative state. Thus a child who showed no change from his pre-operative state would have a score of 7, while a child who had improved in all criteria would have a score of 14. Results were rated according to the scale: score 13-14 excellent; 11-12 good; 9-10 fair; and 8 or less, failure. As mentioned earlier, adequate data were available for the evaluation of 28 of the 32 children. Of these 28, the results were judged to be excellent in 16 children and good in 11; the remaining case was a failure. This last child had undergone two rotational osteotomies to his right lower extremity during the year following adductor surgery, which made it difficult to evaluate the results of the adductor operation. However, he was the only child who did not achieve the objectives of surgery. In addition to the above criteria, it was felt that the surgical procedure might effect a change in the stance phase of knee flexion. However, a comparison of the preoperative movie-films with post-operative examinations showed no significant effect had been achieved. The results showed that the younger children generally received more benefit from the procedure than did the older children. Dividing the 28 children into two groups, 19 aged between four and eight years and nine aged from eight to 16 years, it was found that the younger age-group showed greater improvement in each criterion evaluated. The average 346
WILLIAM H. COUCH, JR.
G. P A U L DEROSA
base of gait improvement was 12cm in the younger group and 7cm in the older; the average combined abduction gain was 67" in the younger group and 58" in the older; and 12 of the 19 patients in the younger group improved their walking ability compared with only one of the nine in the older group.
FRANK B. THROOP
the children who did not decrease their internal rotation after adductor transfer revealed that the tendon of the adductor longus had not been attached to the ischium, but rather anterior to it. The operative notes of these children showed that the adductor longus and gracilis origins had not been taken all the way back to the ischial tuberosity, but simply had been attached in the posterior part of the tendon of the adductor magnus. This was a constant finding in the children who had retained internal rotation of the knee while walking. For this reason we feel that it is imperative that the transferred tendon be placed as far posteriorly as possible on the ischium. We feel very strongly that the lack of complications and the ease of performance are attractive features of the procedure. The increase in 'excellent' results in the younger age-group suggests that the optimum time for this procedure is between four and eight years. We hope that with this procedure we are preventing the bony anatomical changes that take place between the ages of four and 16 years; that is, that we can decrease the anteversion and valgus of the hips by performing the procedure earlier.
Discussion We believe that this study has shed some light upon the rotatory function of the adductor musculature in children with spastic cerebral palsy. In the flexed thigh deformity, the adductors appeared to be strong internal rotators of the femoral segment. By transferring the origins of the adductor longus and gracilis posteriorly to the ischium, the function of internal rotation is negated to a large degree, thereby allowing the adductors to function truly and purely as an adducting force. It should be noted that this procedure was carried out upon ambulatory or near-ambulatory patients, and is not intended to supplant the traditional medial release procedure of adductor myotomy and obturator neurectomy used for prevention of subluxation of the hip. The latter procedure, along with iliopsoas tenotomy, is frequently used in our clinic for the child who has a 'hip at risk'. One of the side benefits from adductor transfer has been the freedom from continuous night splintage which has always been a problem with adductor myotomy. After the first four postoperative weeks in which braces are used for splintage, there is no need for continuous splinting. A critical examination of the records of
AUTHORS' APPOINTMENTS
Dr. William H. Couch, Jr., Staff Orthopedic Surgeon, United States Air Force Hospital, Clark Air Base, Republic of the Philippines. (At the time this study was done Dr. Couch was completing residency training at Indiana University Medical Schools Hospitals.) Dr. G. Paul DeRosa, Assistant Professor of Orthopedic Surgery; Dr. Frank B. Throop, Associate Professor of Orthopedic Surgery; Indiana University Medical School, Indianapolis, Indiana 46202.
SUMMARY
Thigh adductor transfer has been performed on 35 cerebral-palsied children, 32 of whom were available for follow-up. The results were excellent or good in the large majority of cases; only one child did not benefit from surgery. In three cases there were minor compli347
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1977, 19
cations. The procedure is easily performed, with minimal blood loss. The results have been more satisfactory and more predictable than those from other types of surgical approach to the flexed, adducted thigh in cerebral palsy.
RESUME
Transfert des adducteurs pour IMC spastigues 35 sujets prCsentant une diplCgie spastique ont bintficit d’un transfert bilattral des adducteurs pour attCnuer le caractkre replie, en hyper-adduction et en ciseaux de la dCmarche. 32 cas ont pu Ztre suivis par la suite. Objectivement, la mesure de la largeur de la base de sustentation et de 1’Ctendue de I’abduction s’est amCliorCe chez tous les sujets. La rotation des pieds et des genoux au cours de la marche a Ctt significativement amtliorke chez tous les sujets sauf cinq. Le besoin d’aide ambulatoire a diminu6 pour plus de la moitiC des sujets. La mesure de la phase de posture en flexion du genou a montrt une diminution chez la moitiC des sujets. Subjectivement, la dimarche et I’apparence se sont amCliorCes chez tous les sujets sauf un. Les seules complications du proctdt ont CtC deux infections superficielles de l’incision.
ZUSAMMENFASSUNG
Adduktorenverpflanzung bei Cerebralparese Bei 35 Patienten mit spastischer Diplegie wurde eine bilaterale Adduktorenverpflanzung vorgenommen, um die Beugung, die Adduktion und das Uberkreuzen beim Gehen zu vermindern. 32 davon konnten nachuntersucht werden. Ganz objektiv gesehen konnte die Schrittweite und der Abduktionsradius bei allen Patienten verbessert werden. Mit Ausnahme von funf Patienten konnte bei allen die Rotation der FuBe und Kniee beim Gehen verbessert werden. Bei mehr als der Halfte der Patienten konnten die Gehhilfen reduziert werden. Die Knieflexion nahm bei der Halfte der Patienten in der Standphase ab. Subjektiv wurden Gang und Haltung bei allen bis auf einen Patienten verbessert. Die einzigen Komplikationen dabei waren zwei oberflachliche Wund-infektionen.
RESUMEN
Transplante de aductor en la pardisis cerebral espristica A 35 pacientes con diplejia espistica se les practic6 un transplante bilateral de aductor para disminuir su marcha encogida, en aducci6n y en tijeras. Fue posible el estudio continuado en 32 casos. Objetivamente la medici6n de la anchura de la base de la marcha y el margen de aducci6n mejoraron en todos 10s pacientes. La posici6n en rotaci6n de 10s pies y rodillas en la marcha mejor6 significativamente en todos 10s pacientes excepto cinco. La necesidad de ayudas para la deambulaci6n disminuy6 en m i s de la mitad de 10s pacientes. La medicidn de la flexi6n de la rodilla en la bipedestaci6n mostr6 una disminuci6n en la mitad de 10s pacientes. Subjetivamente, la marcha y el aspect0 mejoraron en todos 10s pacientes excepto uno. L as h i c a s complicaciones de tratamiento fue la infeccidn de dos heridas superficiales.
348
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REFERENCES Banks, H. H., Green, W. T. (1960) ‘Adductor myotomy and obturator neurectomy for the correction of the hip in cerebral palsy.’Journalof Bone andJoint Surgery, 42A, 111-126. Barr, J. (1943) ‘Muscle transplantation for combined flexion internal rotation deformity of the thigh in spastic paralysis.’ Archives of Surgery, 46,605-607. Brunnstrom, S. (1966) Clinical Kinesiology. 2ndedn. Philadelphia: F. A. Davis. Donovan, J. (1974) Personal communication. Durham, H. (1938) ‘A procedure for the correction of internal rotation of the thigh in spastic paralysis.’ Journal of Bone and Joint Surgery, 20, 339-344. Frost, H. M. (1971) ‘Cerebral palsy. The spastic crouch.’ Clinical Orthopedics and Related Research, 80,2-8. Green, W. T., McDermott, L. S. (1942) ‘Operative treatment of cerebral palsy of the spastic type.’Journal of the American Medical Association, 118, 434-440. Hollinshead, W. H. (1969) Anatomy for Surgeons. VoZ. 3. The Back andLimbs. 2nd edn. New York: Harper & Row. Nickel, V. L. (1974) Personal communication. - Perry, J., Garrett, A. L., Feiwell, E. M. (1966) ‘Paralytic dislocation of the hip.’ Journal of Bone and Joint Surgery, 48A, 1021.
349
Thigh Adductor Transfer for Spastic Cerebral Palsy William H. Couch, Jr. G. Paul DeRosa Frank B. Throop
Introduction The child with cerebral palsy often displays a gait characterized by flexion, adduction and internal rotation of the thighs, with flexion at the knees. Many authors have attributed the flexed and adducted position of the thigh to spasticity of the thigh flexor and adductor muscles. However, the muscles responsible for the internal rotation deformity have been the subject of much controversy. Most anatomists agree that the tensor fascia lata and the anterior one-third of the gluteus minimus and medius act as internal rotators of the thigh at the hip. With increasing flexion, the function of internal rotation is enhanced. The adductor musculature has an obvious function in flexion and adduction, but its rotatory function is controversial. Hollinshead (1969) ascribes internal rotation function to the gracilis and the posterior portion of the adductor magnus, but admits that there is disagreement as to the rotatory function of the adductor longus and brevis. Brunnstrom (1966) states that the function of the adductor brevis and longus may be either internal or external rotation, depending upon the position of the thigh
in relation to the trunk. He further notes that one may palpate contraction of the adductors when the patient is asked to voluntarily internally rotate the thigh, but not feel such contraction upon voluntary external rotation. Frost (1971) has noted the previously-mentioned flexion, adduction and internal rotation of the hip and has aptly called it ‘the spastic crouch’. He feels that in the position of flexion and adduction the adductor muscles primarily produce an internal rotatory force. Various surgical procedures have been formulated and carried out in an effort to decrease the internal rotatory position in the spastic crouch. Durham (1938) describes a procedure for the relief of internal rotation of the thigh in spastic paralysis which involves sectioning the tensor fascia lata and the anterior one-third of the gluteus medius and minimus muscles. He claimed good results in all the procedures he performed. Barr (1943) reported a procedure for the correction of spastic internal rotation and flexion of the thigh by means of posterior transfer of the origins of the tensor fascia lata and the anterior one-third of the gluteus medius and minimus muscle mass. He noted,
Correspondence to William H. Couch, Jr., M.D., Staff Orthopedic Surgeon, United States Airforce Hospital, Clark Air Base, Republic of the Philippines.
343
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1977, 19
thighs, the operative field is draped. The surgeon sits facing the legs and begins a skin incision just superior to the taut tendon of the adductor longus and extends it posteriorly in a straight line to the ischial tuberosity, as nearly as possible in parallel to the borders of the pubic ramus and ischium. After the skin and subcutaneous tissues are divided, selfretaining retractors may be used to facilitate exposure. The tendon of the adductor longus is identified and a heavy tag suture is placed through its tendinous origin. Using electrocautery, the tendon is then severed from its origin on the pubic ramus. The origins of the adductor brevis, gracilis and anterior portions of the adductor magnus are released with electrocautery, making sure to stay directly next to the bone from which they arise. The end-point for this dissection is the inner surface of the obturator foramen and the shining fascia1 structure of the obturator externus. It is usually found that for the adductor longus tendon to reach the ischial tuberosity, the thigh must be extended and adducted. To accomplish this, an assistant cuts the tape from the pelvic stirrup and straightens the leg-holder to extend and adduct the thigh. An incision is then made into the apophysis of the ischial tuberosity. The adductor brevis, magnus and gracilis are pushed posteriorly toward the ischial tuberosity and rolled under the tendon of the adductor longus. By means of softtissue dissection the adductor longus is freed distally from the thigh, placed in a straight line and secured by several nonabsorbable sutures directly into the apophysis of the ischium. The wound is then thoroughly irrigated, the subcutaneous tissue is approximated and the skin closed with an absorbable synthetic suture. The wounds are then sealed with a topical plastic aerosol dressing. The opposite side is then completed in a similar fashion, but
however, that this was primarily for flexion and internal rotation deformities, and if adductor tightness was a significant problem he recommended a simultaneous or prior release of the adductor origin. Green and McDermott (1942) and Banks and Green (1960) described the technique and results of adductor myotomy and anterior branch obturator neurectomy. Initially, Green and McDermott reported a significant number of poor results, which they attributed to recurrence of deformity secondary to insufficient length of immobilization. Later, Banks and Green appeared to be more pleased with the procedure and reported that no child was made worse by it and that hip subluxation and recent dislocations were significantly decreased. The procedure known as adductor transfer was first accomplished in 1955 by Garrett at the Rancho Los Amigos Hospital (Nickel et al. 1966, Nickel 1974) for paralytic dislocation of the hip. The procedure described in the present article has been performed on cerebral-palsied children over the last 10 years at the Shriner’s Hospital for Crippled Children in Houston, Texas (Donovan 1974). Basically, it consists of the transfer of the origin of the adductor longus and gracilis posteriorly to the ischium, with release of the origins of the adductor brevis and the anterior portion of the adductor magnus.
Procedure Under general anesthesia, the patient is placed in the lithotomy position, with the buttocks resting on the end of the operating table. The legs are positioned with pelvic stirrups, and three-inch wide tape is placed just proximally to the knee and attached to the upright of the pelvic stirrup to hold the knee and thighs abducted as far as the tissues will permit. After thorough surgical preparation, including the entire perineum, buttocks, lower abdomen and proximal 344
WILLIAM H. COUCH, JR.
G. PAUL DEROSA
FRANK B. THROOP
of 30 months. Pre-operative movie-film and adequate records were available for all 32 patients at the time of follow-up, but in four cases the films were inadequate to provide the comparison needed for evaluation of post-operative results.
as the leg is extended and adducted it becomes necessary for the surgeon to stand to the side of the patient in order to suture the adductor longus tendon on the second side. The child is placed into long leg-braces with a pelvic band while still on the operating table and is kept in the braces and band for the first four post-operative weeks. During the first two weeks the hip and knee locks are released occasionally for comfort and to allow the child to assume a position of approximately 45" of flexion at the hips while eating. During the second week, active and passive range of motion are begun at the hips and knees while in the braces. Using braces instead of spica casts has prevented the problem of cast sores in these spastic children. The parents are instructed during the child's stay in the hospital to watch carefully for areas of skin pressure, particularly over the heels. All surgical procedures have been performed by the resident house-staff under attending supervision. The average operating time for the bilateral procedure was 1 hour 10 minutes, with a range of 45 minutes to 1 hour 40 minutes. The average blood-loss was ~OCC, with a range of 20 to 200cc. In no case was blood transfusion required. Complications were two superficial wound infections and one case of bilateral heel sores, all of which healed without sequelae after local treatment.
Results Five objective and two subjective criteria were used to evaluate each child at follow-up. The five objective criteria were: (1) width of base of gait; (2) combined abduction of the thighs in flexion; (3) rotation of the knees while walking; (4) rotation of the feet while walking; and (5) change in walking ability within six months of operation. Subjectivedeterminations were: (I) the examiner's opinion of the change in a child's over-all gait by comparing the pre-operative movie-film with the post-operative examination; and (2) the subjective opinion of each child's parents as to the effectiveness of the procedure on the child as a whole. Of the 28 children for whom adequate pre-operative movie-film was available, the width of base of gait was increased in 26, was unchanged in one and slightly decreased in another. The average preoperative base of gait was 13.5cm (range - 15 to +28cm); post-operatively the average had increased to 24cm (range 12 to 37cm). Combined adduction of the thighs in flexion increased in all patients. Preoperatively the average combined abduction was 50" (range 30" to 70"); post-operatively this had increased to an average of 110", with a range of 60" to 160". Pre-operatively, 24 patients displayed internal rotation at the knees while walking, four displayed neutral rotation and none had external rotation. Postoperatively, five patients persisted with internal rotation, 19 showed neutral
FO~~OW-UP Between December 1970 and January 1974, 35 patients underwent bilateral adductor transfer. 32 of the 35 children were available for follow-up and were examined personally. Their ages ranged from 3 years 6 months to 16 years 4 months (mean 7 years 7 months). The postoperative periods at follow-up ranged from 14 months to 51 months, with a mean 345
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
rotation and four had developed external rotation of the knees while walking. Rotation of the feet during walking, while not a direct function of internal rotation of the thigh, showed similar improvement. 21 patients had an in-toed gait pre-operatively, four had neutral rotation and three had out-toed gait. At follow-up eight patients retained an intoed gait, nine had achieved a neutral position and 11 had developed an out-toed gait. Walking ability pre- and post-operatively was evaluated in all 32 patients. Before surgery 12 of the 32 were non-ambulatory. Of the other 20 children, nine used various braces and crutches as aids in walking. Any change in walking ability that had occurred within six months of surgery was judged to be a beneficial result of the procedure, rather than simply normal maturation. Post-operatively all 32 patients were walking. Of the 12 children who had been non-ambulatory before surgery, six were walking unassisted and six were using external aids at follow-up. The 11 children who had been walking unassisted pre-operatively continued to do so. Of the nine children who had been walking with external aids pre-operatively, three were able to walk unassisted at follow-up, three had decreased their needs for external aids and the remaining three continued to walk with the same aids they had used pre-operatively. The object of the operation was to improve the functional and ambulatory ability of the child as a whole, and to improve the cosmetic appearance of the patient’s gait. Judging from the 28 preoperative movie-films that were adequate, the examiner’s opinion was that all 28 patients showed an improvement in gait and functional ability. The 32 parents were asked to assess the value of the operation for their child: 31 said that it had helped and only one
1977, 19
parent felt that the child was worse as a result. Rating of Post-operative Improvement
An arbitrary rating system was devised to grade the results of the procedure, based on the above criteria. Two points were awarded for an improvement in each criterion, one point for no change and zero if the child was worse compared with the pre-operative state. Thus a child who showed no change from his pre-operative state would have a score of 7, while a child who had improved in all criteria would have a score of 14. Results were rated according to the scale: score 13-14 excellent; 11-12 good; 9-10 fair; and 8 or less, failure. As mentioned earlier, adequate data were available for the evaluation of 28 of the 32 children. Of these 28, the results were judged to be excellent in 16 children and good in 11; the remaining case was a failure. This last child had undergone two rotational osteotomies to his right lower extremity during the year following adductor surgery, which made it difficult to evaluate the results of the adductor operation. However, he was the only child who did not achieve the objectives of surgery. In addition to the above criteria, it was felt that the surgical procedure might effect a change in the stance phase of knee flexion. However, a comparison of the preoperative movie-films with post-operative examinations showed no significant effect had been achieved. The results showed that the younger children generally received more benefit from the procedure than did the older children. Dividing the 28 children into two groups, 19 aged between four and eight years and nine aged from eight to 16 years, it was found that the younger age-group showed greater improvement in each criterion evaluated. The average 346
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G. P A U L DEROSA
base of gait improvement was 12cm in the younger group and 7cm in the older; the average combined abduction gain was 67" in the younger group and 58" in the older; and 12 of the 19 patients in the younger group improved their walking ability compared with only one of the nine in the older group.
FRANK B. THROOP
the children who did not decrease their internal rotation after adductor transfer revealed that the tendon of the adductor longus had not been attached to the ischium, but rather anterior to it. The operative notes of these children showed that the adductor longus and gracilis origins had not been taken all the way back to the ischial tuberosity, but simply had been attached in the posterior part of the tendon of the adductor magnus. This was a constant finding in the children who had retained internal rotation of the knee while walking. For this reason we feel that it is imperative that the transferred tendon be placed as far posteriorly as possible on the ischium. We feel very strongly that the lack of complications and the ease of performance are attractive features of the procedure. The increase in 'excellent' results in the younger age-group suggests that the optimum time for this procedure is between four and eight years. We hope that with this procedure we are preventing the bony anatomical changes that take place between the ages of four and 16 years; that is, that we can decrease the anteversion and valgus of the hips by performing the procedure earlier.
Discussion We believe that this study has shed some light upon the rotatory function of the adductor musculature in children with spastic cerebral palsy. In the flexed thigh deformity, the adductors appeared to be strong internal rotators of the femoral segment. By transferring the origins of the adductor longus and gracilis posteriorly to the ischium, the function of internal rotation is negated to a large degree, thereby allowing the adductors to function truly and purely as an adducting force. It should be noted that this procedure was carried out upon ambulatory or near-ambulatory patients, and is not intended to supplant the traditional medial release procedure of adductor myotomy and obturator neurectomy used for prevention of subluxation of the hip. The latter procedure, along with iliopsoas tenotomy, is frequently used in our clinic for the child who has a 'hip at risk'. One of the side benefits from adductor transfer has been the freedom from continuous night splintage which has always been a problem with adductor myotomy. After the first four postoperative weeks in which braces are used for splintage, there is no need for continuous splinting. A critical examination of the records of
AUTHORS' APPOINTMENTS
Dr. William H. Couch, Jr., Staff Orthopedic Surgeon, United States Air Force Hospital, Clark Air Base, Republic of the Philippines. (At the time this study was done Dr. Couch was completing residency training at Indiana University Medical Schools Hospitals.) Dr. G. Paul DeRosa, Assistant Professor of Orthopedic Surgery; Dr. Frank B. Throop, Associate Professor of Orthopedic Surgery; Indiana University Medical School, Indianapolis, Indiana 46202.
SUMMARY
Thigh adductor transfer has been performed on 35 cerebral-palsied children, 32 of whom were available for follow-up. The results were excellent or good in the large majority of cases; only one child did not benefit from surgery. In three cases there were minor compli347
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1977, 19
cations. The procedure is easily performed, with minimal blood loss. The results have been more satisfactory and more predictable than those from other types of surgical approach to the flexed, adducted thigh in cerebral palsy.
RESUME
Transfert des adducteurs pour IMC spastigues 35 sujets prCsentant une diplCgie spastique ont bintficit d’un transfert bilattral des adducteurs pour attCnuer le caractkre replie, en hyper-adduction et en ciseaux de la dCmarche. 32 cas ont pu Ztre suivis par la suite. Objectivement, la mesure de la largeur de la base de sustentation et de 1’Ctendue de I’abduction s’est amCliorCe chez tous les sujets. La rotation des pieds et des genoux au cours de la marche a Ctt significativement amtliorke chez tous les sujets sauf cinq. Le besoin d’aide ambulatoire a diminu6 pour plus de la moitiC des sujets. La mesure de la phase de posture en flexion du genou a montrt une diminution chez la moitiC des sujets. Subjectivement, la dimarche et I’apparence se sont amCliorCes chez tous les sujets sauf un. Les seules complications du proctdt ont CtC deux infections superficielles de l’incision.
ZUSAMMENFASSUNG
Adduktorenverpflanzung bei Cerebralparese Bei 35 Patienten mit spastischer Diplegie wurde eine bilaterale Adduktorenverpflanzung vorgenommen, um die Beugung, die Adduktion und das Uberkreuzen beim Gehen zu vermindern. 32 davon konnten nachuntersucht werden. Ganz objektiv gesehen konnte die Schrittweite und der Abduktionsradius bei allen Patienten verbessert werden. Mit Ausnahme von funf Patienten konnte bei allen die Rotation der FuBe und Kniee beim Gehen verbessert werden. Bei mehr als der Halfte der Patienten konnten die Gehhilfen reduziert werden. Die Knieflexion nahm bei der Halfte der Patienten in der Standphase ab. Subjektiv wurden Gang und Haltung bei allen bis auf einen Patienten verbessert. Die einzigen Komplikationen dabei waren zwei oberflachliche Wund-infektionen.
RESUMEN
Transplante de aductor en la pardisis cerebral espristica A 35 pacientes con diplejia espistica se les practic6 un transplante bilateral de aductor para disminuir su marcha encogida, en aducci6n y en tijeras. Fue posible el estudio continuado en 32 casos. Objetivamente la medici6n de la anchura de la base de la marcha y el margen de aducci6n mejoraron en todos 10s pacientes. La posici6n en rotaci6n de 10s pies y rodillas en la marcha mejor6 significativamente en todos 10s pacientes excepto cinco. La necesidad de ayudas para la deambulaci6n disminuy6 en m i s de la mitad de 10s pacientes. La medicidn de la flexi6n de la rodilla en la bipedestaci6n mostr6 una disminuci6n en la mitad de 10s pacientes. Subjetivamente, la marcha y el aspect0 mejoraron en todos 10s pacientes excepto uno. L as h i c a s complicaciones de tratamiento fue la infeccidn de dos heridas superficiales.
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WILLIAM H. COUCH, JR.
G. PAUL DEROSA
FRANK B. THROOP
REFERENCES Banks, H. H., Green, W. T. (1960) ‘Adductor myotomy and obturator neurectomy for the correction of the hip in cerebral palsy.’Journalof Bone andJoint Surgery, 42A, 111-126. Barr, J. (1943) ‘Muscle transplantation for combined flexion internal rotation deformity of the thigh in spastic paralysis.’ Archives of Surgery, 46,605-607. Brunnstrom, S. (1966) Clinical Kinesiology. 2ndedn. Philadelphia: F. A. Davis. Donovan, J. (1974) Personal communication. Durham, H. (1938) ‘A procedure for the correction of internal rotation of the thigh in spastic paralysis.’ Journal of Bone and Joint Surgery, 20, 339-344. Frost, H. M. (1971) ‘Cerebral palsy. The spastic crouch.’ Clinical Orthopedics and Related Research, 80,2-8. Green, W. T., McDermott, L. S. (1942) ‘Operative treatment of cerebral palsy of the spastic type.’Journal of the American Medical Association, 118, 434-440. Hollinshead, W. H. (1969) Anatomy for Surgeons. VoZ. 3. The Back andLimbs. 2nd edn. New York: Harper & Row. Nickel, V. L. (1974) Personal communication. - Perry, J., Garrett, A. L., Feiwell, E. M. (1966) ‘Paralytic dislocation of the hip.’ Journal of Bone and Joint Surgery, 48A, 1021.
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