CONTRACTURE OF THE HAM STRINGS IN SPASTIC CEREBRAL PALSY

A Study of Three M ethods of Operative Correction

JORGEN REIM ERS, COPENHAGEN, DENM ARK
From the Orthopaedic Hospital, Copenhagen
The aim of this prospective study of postural fiexion deformity of the knee in spastic
cerebral palsy was to acquire some experience of proximal elongation of the hamstrings, and
then to compare the results of three different methods of operative correction. It was hoped
in this way to establish the indications for treatment and the choice of operation.
The reason why spastic patients often stand and walk with fiexion deformity of the knee
may be flexion deformity of the hip ; the former often diminishes on correction of the latter
(Roosth 1971, Reimers 1973). If knee fiexion still persists on weight-bearing it must be due
to imbalance between the extensors and fiexors, an imbalance that will gradually lead to the
development of contracture of the stronger flexors, the hamstrings (Sharrard 1967).
Contracture of the hip fiexors is assessed with the patient lying supine on a flat surface.
The opposite hip is flexed just enough to flatten the lumbar spine. The degree of contracture
is then measured as the angle through which the thigh is raised (Fig. 1).
, ; / // V /l///// ;:: , , , F
FIG. 1 FIG. 2
Figure 1-The angle v indicates the degree of hip flexion deformity. Figure 2-The angle v indicates the
degree of contracture of the hamstrings.
Contracture of the hamstrings used to be observed by lifting the extended leg passively
from the supporting surface, and then noting the angle between the leg and the surface when
the pelvis started to tilt in spite of passive resistance (Seymour and Sharrard 1969). This
method, however, can be employed only when complete passive extension of the knee joint is
possible. Since I 969 we have measured the angular deficit from passive full extension when
the ipsilateral hip is flexed 90 degrees (Holt 1965) (Fig. 2). By carrying out the movement
more rapidly, an impression is obtained of the degree of spasticity in the muscles and hence
of the functional contracture.
W ith an organic contracture of the hamstrings up to 40 degrees, corresponding to a
functional or spastic contracture of about 60 degrees, it has been our experience that the
patient may still be able to extend the knee on standing, but that there is usually a flexion
attitude on walking. W ith an organic contracture exceeding 45 degrees it is not possible to
extend the knees even in the standing position ; in every such case the patient sinks down into
knee fiexion when he tires. On the other hand, those patients who are able to walk with
extended knees in spite of contracture of the hamstrings, do so with stiff legs and therefore
have difficulty in lifting their feet off the ground. If the patient wishes to flex the knee and
lift the foot from the ground, he is unable to extend the knee before the standing phase on
account of the functional contracture. The pelvis rotates simultaneously with the leg which
102 THE JOURNAL OF BONE AND JOINT SURGERY
CONTRACTURE OF THE HAMSTRINGS IN SPASTIC CEREBRAL PALSY 103
voL. 56 B, NO. 1, FEBRUARY 1974
is swung forward, and the stride is short because the distance between the origin of the
hamstrings from the ischial tuberosity and their insertion into the tibia becomes greater in
the swing phase (Fig. 3). Factors such as age, intelligence, and the degree of palsy and
spasticity obviously influence function to a great extent.
FIG. 3 FIG. 4
Figure 3-A diagram to show how contracture of the
hamstrings results in knee flexion, foot deformity, short
length of stride and rotation of the pelvis. Figure 4-A
diagram to show how contracture of the hamstrings
produces a lumbar kyphosis when the patient is sitting.
The sitting position is compromised in a corresponding manner when the capacity for
flexion of the hip decreases. In milder cases there is a lumbar kyphosis if the patient has to
sit on a couch with extended legs. W ith more pronounced contracture this kyphosis also
occurs when the patient sits in a chair with flexed knees, and on a smooth chair the patient
tends to slide down (Fig. 4).
If the fiexion attitude of the knee remains untreated, fixed flexion often develops. This
is measured by the angular deficit from full passive extension with the hip extended.
THE M ETHODS OF OPERATION EM PLOYED
M odified Eggerss operation-This procedure (Eggers and Evans 1963) comprised Z-shaped
elongation of the biceps femoris, division of the gracilis, and transposition of the semi-
tendinosus and semimembranosus to the femoral condyle under tension. The additional
procedures of Eggers-sectioning of the retinacula patellae and shortening of the ligamentum
patellae-were not employed.
Distal elongation of the ham strings-This was performed through the same postero-lateral curved
incisions. Gracilis was divided and the other hamstrings lengthened by Z-shaped incisions.
The biceps tendon was not sutured, the tendon being allowed to slide into the muscle so that
some degree of continuity remained. W ith the patient supine after the operation, the extended
leg was lifted so that the hip is flexed to 90 degrees, so as to ensure that sufficient elongation
had been achieved. A long plaster cast was applied with felt padding over heel and knee, and
retained for three weeks. if a passive stretch deficit of extension of the knee was then found,
knee extension splints were used at night. The follow-up treatment was the same as for
proximal elongation.
Proxim al elongation of the hanistrings-This was carried out only when there was at most
5 degrees of arthrogenic flexion deformity of the knee. The patient lies prone with lifted pelvis.
104 J. REIM ERS
At first a longitudinal incision lateral to the ischial tuberosity was made as described by
Seymour and Sharrard (1969), but on account of cheloid formation, we have used a transverse
incision in the natal fold since 1970. The gluteus maximus is held to one side, and medial to
this the hamstrings are isolated close to the ischial tuberosity. Care is taken that the whole
of the sciatic nerve lies lateral to the tuberosity. The muscles are divided close to the origin,
whereas the two tendons are cut about 7 centimetres distally. If the hamstrings are very tight,
it is possible to relax them by flexing the knee. After careful haemostasis the tendons are
sutured to the muscles. If the adductor magnus is contracted and hinders normal flexion of
the hip, then tenotomy may be performed on the broad adductor tendon, which is simply
allowed to retract. if contracture of the gracilis is present, its tendon is resected just proximal
to the knee. Just as in distal elongation, it is important before terminating the narcosis to
lift the extended leg till the hip is flexed 90 degrees. In children up to the age of about twelve
and in patients with pronounced spasticity, it is necessary to apply plaster casts to the thighs,
in order to keep the legs straight during the post-operative period. To achieve abduction of
the hips and control rotation, a cross bar is used (Anthonsen and Reimers 1970).
TABLE I
DETAILS OF THE SIxn PATIENTS
M odified
Eggerss operation
(10 patients)
Distal elongation Proxinial elongation
( 3 tien ) (27 patients)

Distribution . . 10 bilateral
20 bilateral 22 bilateral
3 unilateral 5 unilateral
Hemiplegia 1
Paraplegia 4 Paraplegia 15 Paraplegia 21
Diagnosis . . Tetraplegia 6 Tetraplegia 7 Tetraplegia 6
(Athetosis 3)
(Athetosis 2)
Intelligence quotient 6 >75 per cent >4 17 >75 per cent >6 21 >75 per cent >6
Subluxated 2
Hip joints . . Luxated 1
Subluxated I
Luxated I Subluxated 0
Age . . . 3 to 13 years 4 to 16 years 4 to 48 years
As soon as possible after the operation the patient sits up in bed with legs extended and
tries to touch his toes. The cast may be removed when the extended leg can be lifted passively
through 80 degrees before the pelvis tilts ; this can usually be done two weeks after the operation.
W alking training is then started, during which the patient should have more support than
before the operation for as long as he shows a tendency to sink at the knees. At the same time
he is trained to lift his feet high from the ground and to reactivate the hamstrings.
M ATERIAL
All patients with cerebral palsy who were admitted to the Orthopaedic Hospital,
Copenhagen, from 1968 to 1971 for operative treatment of tight hamstrings are included.
Sixty patients were operated on, with a total of 1 12 operations on the hamstrings. Table I
surveys the material ; it can be seen that the three groups were so different that statistics were
not applicable.
The principle employed in treatment was first to correct any contracture of the hip flexors
over 15 degrees before straightening the knee (Anthonsen 1966). Ifthere was equinus deformity
THE JOURNAL OF BONE AND JOINT SURGERY
CONTRACTURE OF THE HAM STRINGS IN SPASTIC CEREBRAL PALSY 105
of the ankle, elongation of the Achilles tendon was also carried out in order to avoid
hyperextension of the knee. Table II shows the different operations that the patients underwent
apart from operations on the hamstrings.
Table III shows that in 1969 we gave up Eggerss operation, which had been used for
many years, in favour of distal elongation. Since 1970 proximal elongation has been the
standard method, with distal elongation only in the presence of arthrogenic flexion deformity
of the knee exceeding 5 degrees.
TABLE II
SURVEY OF THE ASSOCIATED OPERATIONS
Eggerss operation Distal elongation Proximal elongation
W ith or W ith or W ith or
Before after Before after Before after
Hip flexors (release) - . 3 13 6
Hip adductors (release) . 7 3 10 6 16 4
Tendo achillis (elongation) . 5 2 13 4 25 2
Hamstrings (distal elongation) 2
Patellar (advancement). - I
Femur (osteotomy) . - 1 1
Tarsus (arthrodesis) . . 1 2
TABLE III
DIsTRIBUTION BY YEARS OF THE THREE TECHNIQUES
Eggers s Distal Proxim al
Year dri::iJ elongation elongation
1968 8 2 -
1969 2 16 2
1970 5 25
(1971) (5) (26)
(1972) - (6) (29)
FOLLOW -UP EXAM INATION
The patients were all reviewed at least one year after operation by the doctor who had
seen them before and after the treatment. As the Cerebral Palsy Score for Ambulation was
not ready at the time the patients were operated on, this system (Reimers 1972) could not be
used to record the results.
M odified Eggerss operation-Figure 4 shows that in the ten patients the hip flexion deformities
were more or less unchanged after the operation. On the other hand, all the flexion deformities
of the knee disappeared two to three years after the operation, and only one patient had
5 degrees of hyperextension of both knees. Two patients had to have long braces temporarily
on account of hyperextension. The overall result is that all ten patients have better function
than before the intervention (Fig. 5). The two patients in wheel chair are easier to nurse and
are less spastic; the other patients walk with less support and without long braces. If, however,
VOL. 56B, NO. 1, FEBRUARY 1974
HIPS
66
LLri 11
0#{176} 5#{176} 10#{176} 30#{176} 35#{176}
Before operation
KNEES
4
5#{176} 10#{176}20#{176}
After operation, average 12 years
2-3 years
FIG. 5
A record of the contractures of the hip and knee in ten patients before and after m odified
Eggerss operations.
13 13
I HIPS
66
Lb E11
0#{176} 5#{176}10#{176}15#{176} 20#{176}
Before operation E
35#{176}
FIG. 6
106 J. REIM ERS
THE JOURNAL OF BONE AND JOINT SURGERY
regeneration of one or more of the medial hamstrings to the tibia has not occurred during
the years after the operation, then walking is done with stiff, extended or hyperextended knees
on account of the absence of hamstring function. The sitting position is not improved because
hip fiexion has not been improved.
Distal elongation of the ham strings-Figure 6 shows that in the twenty-three patients the hip
flexion deformities were almost unchanged after the operation. Three patients had 5 degrees
Of flexion deformity of the knee at the time of review. One of these was a patient with a
recurrence, but the contracture was decreasing in the other two.
1 lr- 1
__ - U
_100 50 350
20
13
KNEES
i iO o
00 5#{176}10#{176} 20#{176}
After operation,
average 17 years
A record of the contractures of the hip and knee in twenty-three patients before
and after distal elongation of the hamstrings.
The results show that all twenty-three patients have more or less improved following the
operation. One patient with dislocation of the hip and a low intelligence quotient is still in a
wheel chair, but the kyphosis is less, the knees can be extended and he is easier to nurse. The
other patients can stretch their knees when they stand, most of them also during walking, and
no patient has needed a long brace (Table IV). The length of stride is greater, it is easier to
climb stairs, the feet can be lifted more easily from the ground, and wear on the front of the
sole is less. Several patients now wear shoes instead of boots because the heels reach the
ground. However, three patients started to develop a recurrence eighteen months after the
operation.
Proxim al elongation of the ham strings-Figure 7 shows that in the twenty-seven patients hip
flexion deformity increased 5 degrees in one patient but remained unchanged in all the others.
All the knees can now be extended fully but without hyperextension.
CONTRACTURE OF THE HAM STRINGS IN SPASTIC CEREBRAL PALSY 107
In one patient walking has been further impaired because of a wrong surgical technique.
A longitudinal incision was made directly over the ischial tuberosity ; the cheloid scar ulcerated
and kept the patient prone for months. In two patients function is no better; one walked
27
2121
I HIPS KNEES
4
flj2 _
1 11
L -
0#{176} 5#{176} 10#{176} 20#{176} 0#{176}
Before operation n::: After operation,
average 13 years
FIG. 7
A record of the contractures of the hip and knee in twenty-seven
patients before and after proximal elongation of the hamstrings.
almost normally before the operation but with flexion of the knee, and the other is hypotonic.
There has been considerable improvement in the other twenty-four patiertts (Table IV). One
ofthree patients with pronounced quadriceps spasticity now has much less spasm in this muscle.
A number of patients had a tendency to bend over from the waist immediately after the
operation, but the posture improved in all patients except one during the course ofthe first year.
TABLE IV
SURVEY OF THE PATIENTS ABILrrY TO W ALK BEFORE AND AFTER THE THREE TYPEs OF OPERATION
Eggerss operation Distal elongation
Before After Before After
Proximal elongation
Before After
W heel chair . 2 2 2 1 0 0
Long leg braces . 2 0 3 0 0 0
Personal support. 5 1 5 3 7 2
Rollator . . 1 3 1 1 2 4
Crutches . . 2 3 4 5 6 6
Unaided . . 0 1 Ii 13 12 15
As for complications, one sinus disappeared after spontaneous extrusion of silk sutures.
Almost all the vertical wound scars were cheloid, but only one patient bad discomfort from
this. The horizontal wound scars gave no trouble.
VOL. 56 B, NO. 1, FEBRUARY 1974
108 J. REIM ERS
DISCUSSION
Transposition of the medial hamstrings by a modified Eggerss operation has given quite
good results, but it is not until some regeneration to the tibia occurs after a year or two that
the patient again develops the power of knee flexion. As the sitting position and the length
of stride only improve when the range of flexion of the hip increases, this is not achieved in
an Eggerss operation because it aims at transposing the medial hamstrings to the femur
under tension.
As for distal elongation of the hamstrings, it has been found possible both to correct the
flexion deformity of the knee and to retain the function of the hamstrings for active knee
flexion, without an increase in flexion deformity of the hip.
Inspired by the work of Seymour and Sharrard in 1968 on proximal release of the
hamstrings, we began proximal elongation in 1969, as we did not wish to risk an inadequate
effect on the hip or the knee by merely carrying out the procedure of tenomyotomy. In our
series of twenty-seven patients with proximal elongation, there are two patients who can now
lift the extended leg to 90 degrees before the pelvis tilts. One of these patients walks with
the hips flexed and without hamstring function, but the other patient had the operation on
only the one side, so that it does not matter that the hamstrings have become too long.
Proximal elongation has been found to have advantages over distal elongation. The scar
is less visible in the fold of the buttock than behind the knee, and it is possible to avoid a
cheloid scar by using a horizontal incision. Plaster casts need not be used in most children
or adults without knee flexion deformity, and the period of immobilisation can be reduced to
two weeks compared with three weeks. It is our impression that the hamstrings regain their
function more rapidly after proximal lengthening, and this implies that the patient develops a
good posture more rapidly and can flex his knees actively. One very considerable advantage
is that by proximal elongation of the hamstrings it is possible at the same time to elongate
the adductor magnus or the gluteus maximus if these muscles are hindering normal hip flexion.
Because the short head of biceps femoris is not lengthened in proximal lengthening, the
operation should probably he restricted to cases of arthrogenic knee flexion deformity not
exceeding 5 degrees, an amount which has been found possible to correct. On the other hand,
for milder contracture of the hamstrings it may be sufficient merely to perform tenotomy on
the two tendons at their origin from the ischial tuberosity, leaving the musculature untouched:
it should thus be possible to avoid post-operative immobilisation.
Fifteen of the sixty patients had an intelligence quotient less than 75, two of these also
having dislocation of the hip. All these patients improved after operation of the hamstrings,
even though they could hardly cooperate. This confirms the basic idea of our treatment,
that joints must have an almost normal range ofpassive movement before the spastic patient can
sit, stand and walk as easily and cosmetically normally as possible, in spite of other handicaps.
Another argument for treatment of the spastic patient by orthopaedic surgery is that in
the seven cases of lengthening carried out unilaterally on the side with the greater contracture
of the hamstrings, follow-up examination showed that the leg operated upon had the better
function, quite independently of the primary cerebral defect and reflex disturbances.
The conclusion of this study is that if a spastic patient stands or walks with knee flexion,
or with an extended knee but with a stiff leg and pelvic rotation, and there is an organic
contracture in the hamstrings such that the knee is flexed at least 40 degrees when the hip on
the same side is flexed 90 degrees, and there is a functional contracture of at least 60 degrees,
then there are clear indications for lengthening the hamstrings.
The lengthening is carried out distally when arthrogenic deformity exceeds 5 degrees.
Otherwise it is done proximally, in particular if it is desired to improve the sitting position.
No special allowance need be made for age, intelligence or prognosis as regards walking.
Flexion deformity of the hip may contra-indicate the intervention, particularly when the
abdominal muscles are weak, and with a contracture of 15 degrees the first stage is to correct this.
THE JOURNAL OF BONE AND JOINT SURGERY
CONTRACTURE OF THE HAM STRINGS IN SPASTIC CEREBRAL PALSY 109
SUMMARY
1 . In a prospective study of sixty patients with cerebral palsy and contracture of the
hamstrings, 1 12 operations were performed by three different techniques after any necessary
correction of flexion contracture of the hip or equinus of the ankle.
2. Transposition by the method of Eggers has been abandoned because simple lengthening
has been found to have several advantages.
3. Proximal lengthening, at or near the ischial tuberosity, is employed when fixed flexion of the
knee does not exceed 5 degrees, and is now the standard method. A transverse incision in
the natal fold avoids cheloid formation.
4. Distal lengthening behind the knee is reserved for cases in which the fixed flexion exceeds
5 degrees.
5. After lengthening and weakening of the hamstrings, these spastic patients could stand
more easily and walk with straighter knees, the length ofstride became greater, stairs could be
climbed more easily, the feet could be lifted more from the ground, and the wear on the front
of the sole became less. In addition the sitting position often improved because flexion of the
hips became normal.
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VOL. 56 B, NO. I, FEBRUARY 1974