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

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 linkcopiar

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

Autoria SCIMAGO INSTITUTIONS RANKINGS

Objetivo: Analisar os desfechos: amplitude de movimento, aspectos funcionais, anatômicos e complicações cirúrgicas do alongamento musculotendinoso percutâneo em crianças com paralisia cerebral.

Fontes de dados: Seis bases de dados (Medical Literature Analysis and Retrieval System Online – Medline/PubMed, Cochrane Library, Physiotherapy Evidence Database – PEDro, Latin American and Caribbean Health Sciences Literature – LILACS, Biblioteca Virtual em Saúde – BVS e Scientific Electronic Library Online – SciELO) foram pesquisadas, para estudos entre 2004 e 2024, sobre alongamento musculotendinoso percutâneo em crianças com paralisia cerebral (0–18 anos), com seguimento ≥1 ano. A qualidade dos estudos foi avaliada pela Newcastle-Ottawa Scale e pela Cochrane risk-of-bias.

Síntese dos dados: Quatorze estudos foram incluídos, sendo três ensaios randomizados. Limitações metodológicas foram frequentes: curto tempo de seguimento, variabilidade demográfica, métodos de avaliação não uniformes e ausência de controle de fatores de confusão. Apenas três estudos utilizaram análise tridimensional de marcha. Sete estudos sobre alongamento percutâneo de isquiotibiais mostraram melhora funcional e de amplitude de movimento. Comparações com técnicas abertas não mostraram diferenças cinemáticas consistentes. Três estudos sobre alongamento percutâneo musculotendinoso dos adutores demonstraram aumento da abdução do quadril, sem benefício adicional com procedimentos abertos subsequentes. Três estudos abordaram o tendão de Aquiles: apenas um clínico de longo prazo, com 43% de recorrência sem deformidade do calcâneo; os outros dois trataram de questões anatômicas e pressão compartimental. Um estudo confirmou menor custo e perda sanguínea com a técnica percutânea. Foram relatados aspectos da imobilização pós-operatória e complicações: hipercorreção, recorrência, lesão nervosa e muscular e aumento da inclinação pélvica.

Conclusões: O alongamento musculotendinoso percutâneo pode oferecer benefícios, mas evidências mais robustas e de longo prazo são necessárias para confirmar sua efetividade.

Palavras-chave:
Paralisia cerebral; Procedimentos cirúrgicos minimamente invasivos; Tenotomia; Procedimentos ortopédicos

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.