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Hamstring Lengthening -- Open

Planning

B

Preoperative Plan

1

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • right angle clamp.
  • right angle retractors (e.g. Sofield or Army-Navy)

2

Room setup and equipment

  • standard OR table (Radiolucent if bone procedures being performed also)

3

Patient positioning

  • supine

Technique

D

Skin Incision

1

Make the incision

  • make a 3-5 cm midline incision in the distal third of the posterior thigh.
  • dissection is carried out to expose the semitendinosus medially.
E

Semitendinosus Lengthening

1

Dissect sharply medially to expose the deep fascia.

  • dissect sharply with electrocautery or dissecting scissors.

2

Isolate the semitendinosus

  • the semitendinosus is noted to be the most superficial posteromedial structure and is tendinous distally
  • sharp dissection is used (with electrocautery or dissecting scissors) to expose the deep fascia.
  • incise the deep fascia with tenotomy scissors

3

Place a right angle clamp around the semitendinosus tendon

  • after isolating the semitendinosus, place a right angle clamp around the semitendinosus tendon from lateral to medial
  • lateral to medial placement minimizes the risk of neurovascular damage

4

Transect the semitendinosus

  • the semitendinosus tendon is typically transected at the musculotendinous junction with electrocautery
  • however, if a distal rectus femoris transfer is also being done, the transection is proximal to the musculotendinous junction (to allow enough tendon for the transfer)
F

Semimembranosus lengthening

1

Isolate the semimembranosus

  • incise the fascia over the semimembranosus with tenotomy scissors and isolate the semimembranosus as far anteromedially as possible.

2

Incise the aponeurosis

  • cut the aponeurosis transversely with a 15 blade at 1 or 2 levels
  • leave the underlying muscle undisturbed
  • when 2 cuts are made, the proximal cut is done first so that tissue is still on tension when the distal cut is made

3

Test the release

  • bring the knee into full extension with the ipsilateral hip extended
  • if the knee comes easily to full extension, lateral hamstring lengthening is not needed
  • do NOT check a popliteal angle as this appears to increase the risk of post-operative peroneal neuropraxia
G

Biceps Femoris Lengthening

1

Isolate the biceps femoris

  • sharply dissect laterally (with electocautery or dissecting scissors) through the same midline incision and expose the deep fascia over the biceps femoris
  • incise the deep fascia with dissecting scissors to fully expose the biceps femoris

2

Incise the aponeurotic band

  • incise the fascia over the biceps with a 15 blade
  • identify and isolate the discreet apneurotic band that is located laterally on the biceps
  • transect this band at 1 or 2 levels while leaving the underlying muscle intact
H

Wound Closure

1

Sucbcutaneous closure is with simple sutures of 2-0 absorbable suture

2

Subcuticular closure is with an undyed, running 3-0 absorbable monofilament.

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion, including popliteal angle
  • observe the child walking for visual gait assessment
  • note that if the child toe walks when in AFO braces, the knees are flexed in stance phase
  • identify medical co-morbidities that might impact surgical treatment

2

Review gait analysis, if available.

3

Screen medical studies to identify contraindications to surgery

4

Orders appropriate initial laboratory studies

5

Perform operative consent

  • describe complications of surgery including
  • genu recurvatum -- much more common after combined medial and lateral hamstring lengthening than with isolated medial hamstring lengthening.
  • recurrence
  • neuropraxia
L

Perioperative Inpatient Management

1

Write comprehensive discharge orders

  • knee immobilizers for 16-18 hours daily for 3 weeks.
  • full weight bearing allowed immediately
  • start physical therapy within 1 week
  • pain control
  • diazepam usually very helpful for painful spasms for 5-7 days
  • family can remove dressings in 3-5 days
  • follow-up appointment in 1-2 weeks
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • signs and symptoms
  • physical exam
  • visual gait assessment
  • recognizes factors that could predict complications or poor outcome

2

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

3

Postop: 3-4 Week Postoperative Visit

  • wound check
  • remove the knee immobilizer during the day
  • use a knee immobilizer at night for 6-12 months
  • diagnose and management of early complications
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • post-operative neuropraxia requires allowing the knee to be placed in a flexed position to take tension off the peroneal nerve
  • as nerve recovery ensues, the knee is progressively extended for increasing amounts of time
O

Complex Patient Care

1

Develop a comprehensive preoperative plan that includes options based on intraoperative findings, especially in the setting of single event multilevel surgery (SEMLS)

  • sequencing of intra-operative procedures (e.g. bone versus soft tissue procedures, and proximal versus distal procedures)
 

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