Transplantation of the hamstring muscles in cerebral palsy.

The child suffering from spastic diplegia stands and walks with the hips and knees flexed and with equinus deformity at the ankles. This is an attitude which is a source of embarrassment to an intelligent child and to his friends, a handicap in walking, and often a bar to progress at school or at work. Adduction contractures at the hips are particularly distressing if the child is bedridden because they increase the difficulties of nursing (Pollock and Sharrard 1958, Lamb and Pollock 1962). Eggers (1952) advocated transplantation of the hamstring tendons to the back of the lower femur. This operation relieved the tendency to flexion contracture of the knee while preserving the hamstrings’ effect as hip extensors, and did not demand ofthem any antagonistic function. in an earlier paper Eggers (1950) recommended division of the patellar retinacula to permit full extension of the knee. He found ultimately, however, that better results followed a combination of this retinacular release with transplantation of the hamstrings to the lower end of the femur. Keats and Kambin (1962) claimed with reason that flexion deformity at the knee was caused primarily by muscle imbalance and led to stretching of the patellar tendon ; for this reason he suggested that operations for taking up the slack patellar tendon (Chandler 1933, 1940) would have no permanently beneficial effect unless the imbalance was corrected at the same time. He found that his best results followed a combination of hamstring transplantation with Chandler’s advancement of the patellar attachment more distally on the tibia (Roberts and Adams 1953, Baker 1956). The present assessment of the results of the last ten years has led us to believe that careful selection of the cases is essential. The mental and physical capacity of the patient affect the success of the operation. An appraisal of the criteria for selection of cases seems particularly indicated because it is now considered that it may be justifiable to transplant the tendons into the extensor mechanism of the knee in higher grade spastic patients. We have found that gradual stretching of the patellar retinacula by correction of the flexion contracture of the knee by serial plasters was usually as effective as surgical division. It had the great advantage of preserving the integrity of the quadriceps expansion. it did not increase the laxity of the patellar tendon when the knee was eventually straightened. Muscular imbalance was then corrected by transplantation of the hamstring tendons to the lower end of the femur (after Eggers). This technique has remained fairly constant during ten years although in three recent operations the hamstring tendons have been reattached to the medial and lateral borders of the patella instead of to the femur. Baker and Hill (1964) recorded six cases in which medial rotation at the hip was corrected by transplanting the semitendinosus subcutaneously across the back of the femur to the front of the lateral femoral condyle; this operation was not used in our series.