Percutaneous tendon lengthening and selective percutaneous myofascial lengthening in children with cerebral palsy: Establishing surgical indications using the Delphi method

Purpose: Percutaneous tendon lengthening (PTL), including selective percutaneous myofascial lengthening (SPML), is popular in cerebral palsy (CP) with advocates arguing that it is minimally invasive and may result in less pain and faster rehabilitation than open techniques, but supporting evidence is limited. The purpose of this study was to develop consensus for the surgical indications of PTL and SPML in CP. Methods: A 16-member panel, established experts with at least 10 years’ experience in the surgical management of CP, was created to determine opinion consensus on orthopaedic surgical indications. The modified Delphi method was used, utilising a five-level Likert scale. Consensus was defined at 80% of responses being in the highest or lowest two of the five Likert ratings. General agreement was defined as 60%–79%. Results: Thirty-two statements were surveyed; consensus or general achievement was achieved for 22 questions (69%). The panel reached consensus that percutaneous methods for plantar flexor lengthening (PFL) for equinus in CP should be avoided due to the risk of overlengthening. There was disagreement on 10 questions (31%), primarily on the need for more evidence of differences between PTL and SPML. Conclusions: Expert consensus suggests more evidence is needed to establish the safety and efficacy of all types of percutaneous techniques across anatomical levels but confirmed that all percutaneous PFL in CP should be avoided due to the consequences of overlengthening. Significance of Study: In the absence of prospective high-quality evidence, consensus opinion helps guide surgical decision-making for children with CP. Level of evidence: Level IV