Dissertation committee:
Καθηγητής Ορθοπαιδικής Παναγιώτης Ι. Παπαγγελόπουλος, Καθηγητής Ορθοπαιδικής Δημήτριος Σ. Κορρές, Καθηγητής Ορθοπαιδικής Αριστείδης Β. Ζούμπος
Summary:
Aim: to measure and evaluate gross motor function in children with spastic
cerebral palsy after selective percutaneous myofascial lengthening in the lower
extremities.
Materials and Methods: we prospectively studied 58 children (16 boys and 42
girls) with spastic cerebral palsy (spastic diplegia, hemiplegia or
quadriplegia), aged 3-12 years (mean, 6 years) who underwent selective
percutaneous myofascial lengthening in the lower extremities from January 2004
to December 2009. Indications for surgery and participation in the study were
primary contractions that hampered walking and sitting ability of the patients,
and joint subluxations. Contraindications for surgery and indications for
exclusion from the study were previous neurosurgical procedures such as
selective dorsal rhizotomy or intrathecal baclofen infusion, complex disorders
and severe spasticity of the lower extremities who needed combined major
orthopaedic surgery, and poor cognitive function.
Results: Improvement of the GMFM scale at an average of 71.2 points
preoperatively (range, 29-95 points) to 83.2 points (range, 34-98 points)
postoperatively at 24 months and 83.1 points (range, 34-99 units) at 48 months
was observed in all children. Improvement of the GMFM scale was statistically
significant at 12 months after surgery (p= 0.030) and remained significant at
24 months and 48 months, with no statistically significant difference between
the measurements at 24 and 48 months after surgery (p= 1.207).
Forty-eight (48) children showed improvement at the GMFCS system by one or two
levels; the improvement was statistically significant (p = 0.001). Eight
children with level III GMFCS and two children with level IV GMFCS remained
stable at the same level. However, these patients also experienced an
improvement in gross motor function as measured with the GMFM scale.
The mean time duration of the selective percutaneous myofascial lengthening was
14 minutes (range, 1 to 27 minutes). Surgical wounds were minimal (surgical
incisions length of up to 1 cm); no patient experienced complications related
to the surgical wounds immediately postoperative or during the rehabilitation.
Additionally, no patient experienced complications related to the operation,
the primary disease, or the spasticity such as over-lengthening, paralysis or
vascular complications. Three of the patients required a repeat surgical
operation (using the same percutaneous technique) because of persistent
spasticity of the hamstrings and the hip adductor muscles at 8, 14, and 16
months after the primary operation; however, none of these patients was
compliant to the postoperative physical rehabilitation and therapy protocol
that was recommended during discharge from the hospital.
Conclusions: The results of this study, as measured and evaluated with the
GMFCS and GMFM systems showed significant improvement of gross motor function
in the majority of the children after surgery selective percutaneous myofascial
lengthening. Most patients experienced improvement of GMFCS level. This
improvement has significant value as the results of the system GMFCS are
considered consistent over time. Some patients (10 children with GMFCS levels
III and IV) remained stable at the same level; however, these patients also
experienced improvement in gross motor function as measured with the GMFM
scale. Furthermore, selective percutaneous myofascial lengthening is a safe,
minimally invasive technique, with minimal skin incisions; no patient
experienced any complications of the surgical wound (infection, nerve or
vascular injury) or muscle overlengthening until the period of this study.
Keywords:
Cerebral palsy, Spasticity, Myofacial lengthening, Physical rehabilitation, Physical therapy
