Indications for tendon lengthening (Is it appropriate?) (Full Version)

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VagusX -> Indications for tendon lengthening (Is it appropriate?) (February 3, 2004 5:12:00 AM)

Hi everybody,

I have been requested my a doc to supply my opinions on a tendon lengthening procedure on one of my CP teenagers (13 y/o.)

She is a spastic quad with low cognitive levels. She had a tendon lengthening procedure when she was 5 and had a baclofen pump installed 2.5 years ago. Unfortunatly the Baclofen pump did little for her spacticity and actually ended up decreasing her ability to ambulate and move about. Currently she very limited by her spasticity, her lack of focus, and her difficulties with disassociating her movements. When she does want to walk she looks like she is putting every ounce of energy that she has into the task. I continue to work on this goal with her because I would love to see her ambulate for short distances inside of her school.
However part of my conscious thinks that she will not improve in her ability to ambulate in her gait trainer because we have been at a standstill in her ambulatory progress for about 1 year.

I am concerned about this patient going through a procedure that won't necissarily be functional. I am new to pediatrics and have not experienced too many tendon lengthening procedures. I have been told that they are going to be doing a quad/hamstring procedure. I read in Wheelies that a rectus transfer will help swing phase. Clearing the foot is one of our biggest challenges.

What are your feelings on this procedure and has anybody found it to make the difference?

Thanks

Daniel



tc -> Re: Indications for tendon lengthening (Is it appropriate?) (February 3, 2004 9:53:00 PM)

Hi,
That's great the MD asked your opinion. I'm curious about the MD's main reason for considering the surgery. Is it to gain range or to improve function? Also, what do you mean by "quad/hamstring procedure"? Do you mean a hamstring lengthening or a tendon transfer? If the main problem is knee flexion contracture (what is the popliteal angles?) has the MD thought about a trial of serial casting first to be more conservative to get the ROM? Especially in a child who is already really working hard at moving, the Sx could just weaken her more.



VagusX -> Re: Indications for tendon lengthening (Is it appropriate?) (February 4, 2004 12:05:00 PM)

Yes I am always pleased when I have a MD that wants to hear my opinion. IT only makes sense because I have spent so much time with her.

On to some of your questions. I have yet to actually talk to the MD about the procedure. I was forwarded the message through the parents. The parents filled me on what they got out of the talk and told me to contact the MD about what my goals and opinions of a "hamstring lengthening" and "rectus transfer sx." Thats about the extent of what I know for right now. The father also said that the MD's intentions were to fully extend the leg.

Is it to gain range or to improve function?

I would hypothesize that the procedure would be used to improve function because the parents are really pushing for her to ambulate. ROM passivly is not a problem at the knees. Her popliteal angle is 147 on the left and 143 on the right during stance. As I read the cutoff for HS lengthening in ~ 135 so I am a little confused about why a HS lengthening would be warrented.

I may be able to see a rectus transfer to help improve knee extension but like you said tc, the weakening that could be associated with the treatment may not make the prcedure worth it.

As far as serial casting, this has not been addressed. Once I talk to him I can see what he has to say.

To add one more concern. Her age (13 yo) and her running into puberty soon may cause lot of long bone growth may add complications to HS lengthening tendon transfer procedure.



tc -> Re: Indications for tendon lengthening (Is it appropriate?) (February 4, 2004 6:08:00 PM)

Hi,
It sounds as if you are in a tough spot. I assume that the girl is in a w/c most of the time at school. If you are school-funded, at least with the laws in my state, working on ambulation may not even be an acceptable educationally-relevant classroom goal any more, especially since she has not made progress with it in 1 year.
Anyhow, the things that would really concern me about the tendon lengthening are 1. she didn't respond well to it before and 2. the baclofen pump seemed to decrease her independence and 3. your point about her possible growth spurt soon due to age. Tendon lengthening is usually done to increase range, but it also weakens the muscle and requires a LOT of work afterwords, which usually means by the PT, by the parents with the HEP and especially motivation by the child. Otherwise, you can just be making the problem worse. Sometimes these kids rely on their spasticity to function, and if you weaken it you take away function.
However, you said her range is fine passively, so is it the dynamic tone kicking in that limits the popliteal angles in standing? Can you get her to neutral in knee extension in supine or prone?
The tendon transfer may be more warranted, but the same problems with weakening and maybe even more importantly with this child, is motivation. If she has no motivation now, boy will it decrease after major surgery when she is in pain and then had casts on for a long time. Do you know Billi Cusick's measurements for popliteal angles? Where you have the child in supine, hip flexed to 90 and then extend the knee as much as possible? (You record the measurement as -whatever degrees they are missing to come to neutral) What is that measurement? That can give you another indication of if serial casting could improve range(or if range is the problem or if it is just dynamic tone). If you tell me the measurements, I can cross-reference it with the norms chart to see how limited the child is.
Sorry, this answer seems very convoluted. But in a nutshell, bring your concerns (and any that I've brought up that seem relevant) to the MD. I think it is best to start conservative with this child given her history with surgical intervention and her decreased level of motivation. You may need to increase the education for the parents on how the child's motivation to walk is essential for her to achieve that goal and that outside intervention (PT, Sx) cannot force her to do something she does not want to do. (Just make it sound nicer than that! [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] )



tc -> Re: Indications for tendon lengthening (Is it appropriate?) (February 3, 2004 9:53:00 PM)

Hi,
That's great the MD asked your opinion. I'm curious about the MD's main reason for considering the surgery. Is it to gain range or to improve function? Also, what do you mean by "quad/hamstring procedure"? Do you mean a hamstring lengthening or a tendon transfer? If the main problem is knee flexion contracture (what is the popliteal angles?) has the MD thought about a trial of serial casting first to be more conservative to get the ROM? Especially in a child who is already really working hard at moving, the Sx could just weaken her more.



VagusX -> Re: Indications for tendon lengthening (Is it appropriate?) (February 4, 2004 12:05:00 PM)

Yes I am always pleased when I have a MD that wants to hear my opinion. IT only makes sense because I have spent so much time with her.

On to some of your questions. I have yet to actually talk to the MD about the procedure. I was forwarded the message through the parents. The parents filled me on what they got out of the talk and told me to contact the MD about what my goals and opinions of a "hamstring lengthening" and "rectus transfer sx." Thats about the extent of what I know for right now. The father also said that the MD's intentions were to fully extend the leg.

Is it to gain range or to improve function?

I would hypothesize that the procedure would be used to improve function because the parents are really pushing for her to ambulate. ROM passivly is not a problem at the knees. Her popliteal angle is 147 on the left and 143 on the right during stance. As I read the cutoff for HS lengthening in ~ 135 so I am a little confused about why a HS lengthening would be warrented.

I may be able to see a rectus transfer to help improve knee extension but like you said tc, the weakening that could be associated with the treatment may not make the prcedure worth it.

As far as serial casting, this has not been addressed. Once I talk to him I can see what he has to say.

To add one more concern. Her age (13 yo) and her running into puberty soon may cause lot of long bone growth may add complications to HS lengthening tendon transfer procedure.



tc -> Re: Indications for tendon lengthening (Is it appropriate?) (February 4, 2004 6:08:00 PM)

Hi,
It sounds as if you are in a tough spot. I assume that the girl is in a w/c most of the time at school. If you are school-funded, at least with the laws in my state, working on ambulation may not even be an acceptable educationally-relevant classroom goal any more, especially since she has not made progress with it in 1 year.
Anyhow, the things that would really concern me about the tendon lengthening are 1. she didn't respond well to it before and 2. the baclofen pump seemed to decrease her independence and 3. your point about her possible growth spurt soon due to age. Tendon lengthening is usually done to increase range, but it also weakens the muscle and requires a LOT of work afterwords, which usually means by the PT, by the parents with the HEP and especially motivation by the child. Otherwise, you can just be making the problem worse. Sometimes these kids rely on their spasticity to function, and if you weaken it you take away function.
However, you said her range is fine passively, so is it the dynamic tone kicking in that limits the popliteal angles in standing? Can you get her to neutral in knee extension in supine or prone?
The tendon transfer may be more warranted, but the same problems with weakening and maybe even more importantly with this child, is motivation. If she has no motivation now, boy will it decrease after major surgery when she is in pain and then had casts on for a long time. Do you know Billi Cusick's measurements for popliteal angles? Where you have the child in supine, hip flexed to 90 and then extend the knee as much as possible? (You record the measurement as -whatever degrees they are missing to come to neutral) What is that measurement? That can give you another indication of if serial casting could improve range(or if range is the problem or if it is just dynamic tone). If you tell me the measurements, I can cross-reference it with the norms chart to see how limited the child is.
Sorry, this answer seems very convoluted. But in a nutshell, bring your concerns (and any that I've brought up that seem relevant) to the MD. I think it is best to start conservative with this child given her history with surgical intervention and her decreased level of motivation. You may need to increase the education for the parents on how the child's motivation to walk is essential for her to achieve that goal and that outside intervention (PT, Sx) cannot force her to do something she does not want to do. (Just make it sound nicer than that! [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] )



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