Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV

Rectus femoris surgery for the correction of stiff knee gait in cerebral palsy: A systematic review and meta-analysis

INTRODUCTION

Rectus femoris (RF) transfer was long the gold-standard treatment for stiff knee gait (SKG), but efficacy now seems less than that of distal RF release. The aim of the present study was to compare efficacy between the two. The study hypothesis was that both significantly improve 4 knee kinematic parameters at 1 year.

PATIENTS AND METHOD

A meta-analysis was performed, using PRISMA criteria, on the Medline, Science Direct, Cochrane Registry, Scopus and Pascal databases. Search was conducted up to March 1, 2020 by two authors (A.J & M.T). Study methodology was assessed on MINORS index. Inclusion criteria comprised patients with SKG, treated by RF transfer or distal release. Endpoints comprised: Peak Knee Flexion in swing phase (PKFSW), Knee Range of Motion (KROM), time to Peak Knee Flexion (t-PKFGC), and Maximum Knee Extension in stance phase (MKEST). Effect size was assessed on Standard Mean Deviation (SMD).

RESULTS

A total of 695 studies were identified, 16 of which were included: 14 transfer, 5 release. Data were analyzed for 1,079 limbs in 768 patients. Only transfer improved PKFSW, with small effect size (SMD=0.29). The other three parameters were improved by both techniques, with moderate effect size.

DISCUSSION

Results showed improved knee kinematics after RF transfer, but with small or moderate effect size. The effect of distal release on PKF could not be assessed, due to publication bias. The heterogeneity of studies and low levels of evidence call for caution in interpreting the present results.

LEVEL OF EVIDENCE

III.

Contribution of Different Impairments to Restricted Knee Flexion during Gait in Individuals with Cerebral Palsy

The coexistence of overlapping impairments modulates the knee pattern in the swing phase of walking in children with cerebral palsy (CP). The impact and contribution of each impairment to the reduction of knee range-of-motion is unknown. The aim of the study was to establish the gradation of the impact of individual coexisting impairments on the knee flexion range-of-motion. Passive range-of-motion, selective motor control, strength, and spasticity from 132 patients (Male = 76, Female = 56, age:11 ± 4 years) with spastic CP were tested with clinical tools. Knee flexion range-of-motion at terminal stance, pre-swing, and initial swing phases were assessed by gait analysis. Hypertonia (β = −5.75) and weakness (β = 2.76) of knee extensors were associated with lower range of knee flexion (R2 = 0.0801, F = 11.0963, p < 0.0001). The predictive factors (R2 = 0.0744, F = 7.2135, p < 0.0001) were strength (β = 4.04) and spasticity (β = −2.74) of knee extensors and strength of hip flexors (β = −2.01); in swing those were knee extensors hypertonia (β = −2.55) and passive range of flexion (β = 0.16) (R2 = 0.0398, F = 3.4010, p = 0.01). Hypertonia of knee extensors has the strongest impact on knee flexion range-of-motion; secondary is the strength of knee extensors. The knee extensors strength with knee extensors hypertonia and strength of hip flexors contributes in stance. Knee extensors hypertonia with passive knee flexion range-of-motion contributes in swing.

The Impact of Patellar Tendon Advancement on Knee Joint Moment and Muscle Forces in Patients with Cerebral Palsy

Background: Patellar tendon advancement (PTA) is performed for the treatment of crouch gait in patients with cerebral palsy (CP). In this study, we aimed to determine the influence of PTA in the context of single-event multilevel surgery (SEMLS) on knee joint moment and muscle forces through musculoskeletal modeling; Methods: Gait data of children with CP and crouch gait were retrospectively analyzed. Patients were included if they had a SEMLS with a PTA (PTA group, n = 18) and a SEMLS without a PTA (NoPTA group, n = 18). A musculoskeletal model was used to calculate the pre- and postoperative knee joint moments and muscle forces; Results: Knee extensor moment increased in the PTA group postoperatively (p = 0.016), but there was no statistically significant change in the NoPTA group (p > 0.05). The quadriceps muscle forces increased for the PTA group (p = 0.034), while there was no difference in the NoPTA group (p > 0.05). The hamstring muscle forces increased in the PTA group (p = 0.039), while there was no difference in the NoPTA group (p > 0.05); Conclusions: PTA was found to be an effective surgery for the treatment of crouch gait. It contributes to improving knee extensor moment, decreasing knee flexor moment, and enhancing the quadriceps and hamstring muscle forces postoperatively.

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait

BACKGROUND

Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA.

METHODS

Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait.

RESULTS

Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group.

CONCLUSIONS

Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries.

LEVEL OF EVIDENCE

Level III-retrospective matched-cohort study.

Distal rectus femoris surgery in children with cerebral palsy: results of a Delphi consensus project

PURPOSE

The purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method.

METHODS

The panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.

RESULTS

Consensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade.

CONCLUSION

This study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.

LEVEL OF EVIDENCE

V.

Recurrence of knee flexion contracture after surgical correction in children with cerebral palsy

PURPOSE

Knee flexion contracture (FC) and crouch gait are challenging to treat in children with cerebral palsy (CCP), and recurrent knee FC after surgery is a severe complication. The aim was to identify factors associated with recurrent knee FC after surgery.

METHODS

The records of 62 CCP (age 10.6±2.6 years) who underwent surgery and were followed for > six months were reviewed. Knee FC was treated by hamstring lengthening, posterior knee capsulotomy, and femoral shortening/extension osteotomy until full extension was obtained. Kaplan-Meier analysis was used to estimate the probability of the correction being maintained. Cox proportional hazard modeling was used to compare parameters between patients with and without recurrent knee FC, with the time to recurrence as the endpoint. Potential confounding factors were included in the multivariate analysis.

RESULTS

In total, the procedure was performed on 122 knees. The average weight-for-age z score was -1.3±1.2. The average follow-up period was 5.4±4.2 years. Knee FC recurrence was observed in 37 knees (30%). The average recurrence-free time was 4.9 years, with most cases of recurrence (33 knees) occurring within six years after surgery. The factors associated with recurrence were age (HR, 1.19) and a required posterior knee capsulotomy procedure (HR, 4.53).

CONCLUSION

Recurrent knee FC after correction is associated with CCP who are older at the time of operation and when posterior knee capsulotomy is performed. The age at operation should be optimized. The sequence of procedures should be performed only as necessary to minimize the chance of post-operative muscle weakness and recurrence.

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis

BACKGROUND

Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment.

METHODS

A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review.

RESULTS

The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis.

CONCLUSIONS

Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance.

LEVEL OF EVIDENCE

Level IV-literature review.

Management of the Knee Problems in Spastic Cerebral Palsy

Two common knee problems in cerebral palsy are increased knee flexion during stance phase and reduced knee flexion during the swing phase of gait. We reviewed the recent literature and based on that, we formed this review. Hamstring spasticity, quadriceps weakness, soleus weakness, and lever-arm dysfunction are few factors which lead to increased knee flexion during stance phase. Rectus spasticity diminishes knee flexion in the swing. Resulting gait-stiff knee gait interferes with ground clearance. Both gait patterns result into esthetically poor gait and increased energy consumption. Knee flexion gait may lead to pain in the knee. Natural history of knee flexion gait suggests deterioration over time. In the early stage, these gait abnormalities are managed by nonoperative treatment. Cases in which nonoperative measures fail or advance cases need surgical treatment. Various variables which are taken into consideration before selecting a particular treatment option are described. We also present an algorithm for decision-making. Nonsurgical options and surgical procedures are discussed.