Distal Femoral Extension Osteotomy and Patellar Tendon Advancement in Management of Fixed Knee Flexion Deformity and Crouch Gait in Cerebral Palsy

Background Cerebral palsy (CP) is generally associated with musculoskeletal deformities that occur during body growth. Fixed knee flexion deformity (FKFD) results from long standing knee flexion that is due to progressive contracture of spastic hamstrings combined with a quadriceps weakness. Fixed knee flexion compromises the passive mechanisms of joint stabilization at mid and terminal stance in children with CP. The aim of this study is to highlight the results of distal femoral extension osteotomy and patellar tendon advancement (DFEO + PTA) for management of FKFD in crouching CP patients with spastic or mixed tone diplegic ambulatory cerebral palsy children. Patients and Methods A prospective study was conducted involving twenty CP patients with fixed knee flexion deformity (14 males and 6 females). The 20 cases with fixed knee flexion deformity were GMFCS level II (4 cases), and III (16 cases). All patients were clinically and radiologically assessed according to knee flexion angle, extension lag, koshino index and the Gross motor function measure pre- and post-operative. All patients underwent DFEO ± PTA. Eighteen limbs had DFEO on the RT side, and twenty on the LT side. Results The mean age of the patients was 11.18±3.23 (6-16) years. The period of follow up ranged from 12 to 24 months (The mean follow up was 16.20 ± 2.46). At last follow up, the median knee flexion angle improved from 25 to 0. The median extension lag improved from 17.5 to 0. The mean koshino index improved from 1.59 ± 0.32 to 1.05 ± 0.10. the GMFM improved from 52.86 ± 7.36 to 68.15 ± 5. 82. Conclusion The combined procedure (DFEO + PTA) is effective in increasing knee extension in the stance phase, reducing knee pain and improving knee extension strength.

Comparison between semitendinosus transfer to distal femur and medial hamstrings surgical lengthening for treatment of flexed knee gait in cerebral palsy

Purpose: Hamstrings surgical lengthening (HSL) has been frequently used for the treatment of flexed knee gait in cerebral palsy; however, recurrence of knee flexion deformity (KFD) and increase of anterior pelvic tilt (APT) were reported in a long-term follow-up. Research question: The aim of this study was to compare semitendinosus transfer to distal femur (STTX) and semitendinosus surgical lengthening (STL) regarding the reduction of KFD and the increase of APT after flexed knee gait treatment. Methods: One hundred and eleven patients were evaluated and they were divided into two groups according to surgical procedures at knees: group A (65 patients/130 knees), including patients who received medial HSL as part of multilevel approach; group B (46 patients/92 knees), represented by patients who underwent orthopedic surgery including an STTX instead of STL. Results: Fixed knee flexion deformity (FKFD) decreased only in group B (from 6.79° to 2.96°, p < 0.001) after intervention. In kinematics, APT increased from 16.38° to 19.03° in group A ( p = 0.003), while group B also increased from 15.26° to 20.59° ( p < 0.001). The minimum knee flexion in stance phase (MKFS) reduced from 25.34° to 21.65° ( p = 0.016) in group A and from 31° to 19.57° ( p < 0.001) in group B. In the comparison between groups A and B, the increase of APT ( p = 0.028) and reduction of FKFD ( p < 0.001), popliteal angle ( p = 0.001), bilateral popliteal angle ( p = 0.003) and MKFS ( p = 0.006) were higher after STTX than STL. Conclusion: In the present study, patients who received STTX exhibited more improvement of knee extension at clinical examination and during gait than those who underwent to STL; however, STTX was not effective to prevent the increase of APT after flexed knee gait treatment.

Guided Growth for Correction of Knee Flexion Contracture in Patients with Arthrogryposis: Preliminary Results

Background. Knee flexion contractures frequently present in children with arthrogryposis and significantly alter kinematics of walking and reduce efficiency of ambulation or render it impossible. There are variety of surgical options for contracture correction, including entire soft-tissue release or its combination with Ilizarov ex-fix and supracondylar femoral osteotomy. Choosing of the most effective surgery is challenging because every method has limitations.Aim. To evaluate the treatment outcomes of knee flexion deformity correction by guided growth in patients with arthrogryposis.Materials and methods. A total of 12 patients (20 knee joints) with arthrogryposis who underwent anterior distal femoral hemiepiphysiodesis with 8 plates for knee flexion contracture correction were included in the study. The average age at surgery was 6.5 ± 0.5 (range, 4.3–9.6) years. Clinical and radiological methods were used with statistical analysis of the data.Results. The mean preoperative knee flexion deformity angle was 48.5° ± 4.04° (range, 20°–80°). After distal femoral hemiepiphysiodesis, a reduction of knee flexion contracture was observed in 17 (85%) patients during a follow-up period of 18–36 months. The average correction was 20° ± 2.67° (range, 0°–40°) (p < 0.05). The residual deformity angle was 28.5° ± 6.03° (range, 0°–60°). Patients with contractures up to 50° demonstrated the most significant correction (by 90% compared with the initial value) (p < 0.05). This group included patients with severe flexion contractures, treated by serial casting, combined with an extension devise before surgery, which contributed to a significant reduction of the contracture.Conclusion. Distal femoral hemiepiphysiodesis is an effective, safe, and reproducible surgical option for knee flexion contractures in patients with arthrogryposis. Combination with additional methods enables significantly reduction of knee flexion deformities from severe to moderate, thereby rendering treatment more effective with a shorter duration, which allows prompt improvement in ambulatory capacity.