Outcomes of percutaneous musculotendinous lengthening in children with Cerebral Palsy: a systematic review

Tedesco, Ana Paula; Nicolini-Panisson, Renata D’Agostini

doi:10.1590/1984-0462/2026/44/2025294

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REVIEW ARTICLE • Rev. paul. pediatr. 44 • 2026 • https://doi.org/10.1590/1984-0462/2026/44/2025294 linkcopy

Outcomes of percutaneous musculotendinous lengthening in children with Cerebral Palsy: a systematic review

Resultados do alongamento musculotendinoso percutâneo em crianças com Paralisia Cerebral: uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: The aim of this study was to analyze the outcomes — joint range of motion, functional aspects, anatomical aspects, and complications — of percutaneous musculotendinous lengthening in children with cerebral palsy.

Data source: In total, six databases were searched (Medline/PubMed, Cochrane Library, Physiotherapy Evidence Database/PEDro, LILACS, Biblioteca Virtual em Saúde/BVS, and SciELO) for publications from 2004 to 2024 on percutaneous musculotendinous lengthening in children with cerebral palsy (0–18 years), with ≥1 year of follow-up, in English or Portuguese. The quality of nonrandomized studies was assessed using the Newcastle-Ottawa Scale, and that of randomized trials using the Cochrane risk-of-bias tool.

Data synthesis: Of 151 studies identified, 14 met the inclusion criteria, including three randomized trials. Methodological limitations were frequent, including short follow-up periods, demographic heterogeneity, nonuniform evaluation methods, and the lack of confounder control. Only three studies used three-dimensional gait analysis. Notably, seven studies on hamstring percutaneous musculotendinous lengthening showed functional and range-of-motion improvements. Comparisons with open techniques showed no consistent kinematic differences. Evidently, three studies on adductor percutaneous musculotendinous lengthening found increased hip abduction, with no additional benefit from subsequent open procedures. Notably, the literature regarding Achilles issues is limited to three studies; of these, a single long-term clinical trial identified a 43% recurrence rate without calcaneus deformity, whereas the remaining two were restricted to anatomical and compartment pressure-related issues. Significantly, one study confirmed lower costs and blood loss in comparison with open procedures. The use of post-op immobilization and complications — overcorrection, recurrence, nerve and muscle injury, and increased pelvic tilt — were reported.

Conclusions: Percutaneous musculotendinous lengthening may offer benefits, but stronger evidence from high-quality, long-term studies is needed to confirm its effectiveness.

Keywords:
Cerebral palsy; Minimally invasive surgery; Tenotomy; Orthopedic procedures

Study	Goal of study	Type of study	NOS	RoB 2	Level of evidence
Afaque et al.¹⁹	Comparing open vs PML hamstring in spastic diplegia	Randomized controlled trial		Some concerns	II
Ariyawatkul et al.⁹	To measure neurovascular proximity, using ultrasound during PML hamstrings	Prospective observational	High quality: 8		III
Carbonell¹⁰	To measure pressure of the posterior superficial compartment of legs before and after a PML Achilles tendon	Prospective observational	Moderate quality: 5		III
El Hage et al.²⁰	To evaluate the effectiveness and safety of PML adductor longus compared to open procedure	Randomized controlled trial		Low risk	II
Erdal et al.¹¹	To assess neurovascular safety after PML Achilles tendon	Retrospective cohort	Moderate quality: 6		III
Gordon et al.¹⁴	To assess gait outcomes after PML hamstrings	Retrospective cohort	Moderate quality: 6		IV
Hachache et al.²²	To evaluate the effectiveness and safety PML adductor longus and proximal gracilis compared to open.	Prospective comparative cohort	High quality: 7		II
Krupinski et al.¹⁵	To evaluate PML Achilles tendon	Retrospective cohort	Moderate quality: 6		IV
Mansour et al.²¹	To compare PML with open hamstring lengthening	Randomized controlled trial		Low risk	II
Mitsiokapa et al.¹⁶	To evaluate functional impact of PML (adductors, hamstrings).	Retrospective cohort	High quality: 7		IV
Mozafari et al.¹²	To compare open versus PML hamstring	Retrospective cohort	High quality: 8		III
Nazareth et al.¹³	To assess functional outcomes of PML vs open hamstring lengthening	Retrospective cohort	High quality: 8		III
Pierz et al.¹⁷	To assess safety and outcomes of PML hamstring	Retrospective cohort	High quality: 7		IV
Wild et al.¹⁸	To evaluate clinical outcomes after PML hamstring	Prospective case series	Moderate quality: 6		IV

Study	n	Age	Type of spastic CP	GMFCS	Follow-up (months)
Afaque et al.¹⁹	100	9. 5±1.8	Diplegia	I–V	12
Ariyawatkul et al.⁹	16 (32 knees)	7.9	Diplegia, quadriplegia	--	N/A
Carbonell¹⁰	18 (28 legs)	9.1	Quadriplegia, hemiplegia	III–IV	N/A
El Hage et al.²⁰	27 (50 hips)	--	--	--	N/A
Erdal et al.¹¹	19 (30 ankles)	11.7	--	--	17.6 (12–26)
Gordon et al.¹⁴	48	9.5	Diplegia, hemiplegia, quadriplegia	I–III	SFU: 11.8 (8.0–17.4) LFU: 33.8 (18.4–69.5)
Hachache et al.²²	31 (59 hips)	8.5	--	I–V	N/A
Krupinski et al.¹⁵	53 (76 feet)	7	Diplegia, hemiplegia	I–II	*10,9 years (3–17)
Mansour et al.²¹	18 (31 knees)	8.5	Diplegia, hemiplegia, paraplegia	--	N/A
Mitsiokapa et al.¹⁶	53	3-12	Diplegia, quadriplegia, hemiplegia	I–IV	24 (6–24)
Mozafari et al.¹²	54 (108 knees)	8.5	Diplegia	I–V	Open:19.1 (12–49)PML: 18.3 (14–45)
Nazareth et al.¹³	87 (open: 65 PML: 22)	8.3	Diplegia, hemiplegia	I–IV	29.4±19.9 Open: 33.1 PML: 19.2
Pierz et al.¹⁷	52	8.2	Diplegia, hemiplegia	I–III	10-49
Wild et al.¹⁸	201 (Phase 1: 17, Phase 2: 184)	7. 6	--	II–IV	Phase 1:6,3(5–13) Phase 2:33,3(27–38)

Study	Procedures	Results
Afaque et al.¹⁹	Open vs PML hamstring	Within-group improvements in GMFCS, FIM, PRS, OGS, PA; no significant difference between groups.
Ariyawatkul et al.⁹	PML hamstring, ultrasound	High risk of peroneal nerve proximity to the lateral hamstring; open technique recommended for the lateral side.
Carbonell¹⁰	PML Achilles tendon, compartment pressure	Pressure of superficial posterior compartment of leg higher in tetraplegia than hemiplegia; significantly decreased after surgery; correlated with degree of plantar flexion.
El Hage et al.²⁰	PML adductor longus followed by open and completion of tenotomy as necessary.	Hip abduction improved after PML; no further gain with open procedure.
Erdal et al.¹¹	PML Achilles tendon, postoperative MRI	Sural nerve — enlargement with degenerative changes: 16,7%, complete transection: 3,3%. Lateral cut >3 cm proximal to Achilles insertion: higher risk; medial side: safe (≥5 mm distance from tendon)
Gordon et al.¹⁴	PML hamstring	Gait analysis: Both groups: improved: KEICd, velocity, GDI; increased stride length and decreased PA. SFU: increased anterior pelvic tilt and knee extension, and decreased plantarflexion at initial contact.
Hachache et al.²²	PML adductor longus and gracilis followed by open	Improvement of abduction after PML; no further gain after open procedure. Bleeding problems.
Krupinski et al.¹⁵	PML Achilles tendon	On clinical observation: Recurrence: 43% (4%<8 years old vs 72% >8 years); good cosmetic and satisfaction outcomes; no calcaneal deformity observed.
Mansour et al.²¹	PML of medial hamstrings, followed by open exploration	Gain in PA less after PML, undesirable cut of the semimembranosus muscle more than 50%: 25%, complete rupture: 19%.
Mitsiokapa et al.¹⁶	PML adductors, hamstrings, fascia lata, sartorius+obturator blocks	GMFCS: improved by 1 level in 34 cases and 2 in 5. GMFM improved 71.19% to 83.19%; all patients except one continued improving GMFM at 24 months.
Mozafari et al.¹²	Open vs PML hamstring+concomitant surgeries	PML associated with shorter surgical time, hospital stay, and lower cost; both techniques improved PA and GMFCS, with no difference between groups.
Nazareth et al.¹³	Open vs PML hamstring+concomitant surgeries	Gait analysis and PA: No difference in ROM or stance phase knee kinematics between groups, increase of anterior pelvic tilt >10°: PML 23%, open 14%.
Pierz et al.¹⁷	PML hamstring	Gait analysis and clinical exam: Both improved in PA, static knee extension, KEICd, mean knee flexion in stance; GMFCS III: increase in pelvic tilt.
Wild et al.¹⁸	PML adductors, hamstrings, gastrocnemius	Phase 1 (video analysis): improved knee/ankle ROM during gait and FMS 5, 50, 500. Phase 2 (telephone interview): FMS 500 continued improvement; FMS 5,50 maintained.

Study	Complications
Afaque et al.¹⁹	None
Ariyawatkul et al.⁹	N/A
Carbonell¹⁰	N/A
El Hage et al.²⁰	Inadvertent partial section of adductor brevis in 12%
Erdal et al.¹¹	N/A
Gordon et al.¹⁴	Recurvatum midstance: SFU:11%, LFU:17%
Hachache et al.²²	Significant bleeding in 66% after PML (51% required hemostasis in open phase); common: minimal injury of adductor brevis; partial injury of obturator nerve (1 case)
Krupinski et al.¹⁵	None
Mansour et al.²¹	None
Mitsiokapa et al.¹⁶	None
Mozafari et al.¹²	Open: 1transitory peroneal nerve palsy, 1 stiff knee /recurvatum required distal transfer of rectus femoris. PML: 1 peroneal nerve palsy, 1 hamstring weakness /hip extension weakness /gluteus lurch—no recovery
Nazareth et al.¹³	PML: no complications. Open: (12%): temporary peroneal neuropraxia (1), hypersensitivity at the plantar aspect of the foot (3), heel pressure sore (3), wound infection (1).
Pierz et al.¹⁷	Recurvatum: 8 (3 had pre-surgery that improved but was still excessive, 1 had normal knee extension pre-surgery, and 4 had increased knee flexion pre-surgery).
Wild et al.¹⁸	Phase 2: 2.4% (hematoma (n=2), paresthesia (n=8), tight casts (n=4), transient flexion contractures (n=11), gracilis muscle rupture (n=1). Reoperation rate: 8%–13%.

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[T1FN1] Notes: The quality of the observational studies analyzed with New Castle-Ottawa Quality Assessment Scale. The Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess the randomized controlled trial studies. Level of evidence estimated according to the Oxford Centre for Evidence-Based Medicine Scale (OCEBM).

[T1FN2] NOS: Newcastle-Ottawa Scale; PML: Percutaneous Musculotendinous Lengthening.