Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

Purpose To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Methods Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Results Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. Conclusion These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor. No financial support was received for this study.     

Treatment of stiff-knee gait in cerebral palsy: a comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release

Two groups of patients with cerebral palsy (CP) were studied pre- and postoperatively by gait analysis after proximal release or distal transfer of the rectus femoris for treatment of knee stiffness in swing phase. In the first group studied, 12 patients underwent proximal rectus femoris muscle release. In the second group, 10 patients underwent distal rectus femoris transfer. After surgery, peak knee flexion was increased 9.1 degrees in swing phase by proximal rectus release and 16.2 degrees by distal rectus transfer. Hip motion throughout the gait cycle was not significantly affected by either operation, and no tendency for a crouch gait was observed after either procedure.     

Intramuscular psoas lengthening improves dynamic hip function in children with cerebral palsy

The efficacy of psoas surgery for the treatment of hip flexor dysfunction in cerebral palsy has long been a subject of debate. A retrospective, repeated-measures analysis was performed to examine the effect of psoas surgery based on gait and clinical and functional measures. The results of this study show that intramuscular psoas lengthening over the pelvic brim is a safe and effective way to improve the hip function of independently ambulatory children with cerebral palsy while maintaining hip flexor power. The data also support the use of the multivariate hip flexor index as an overall measure of hip function.     

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

PurposeThe 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.MethodsThe 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.ResultsConsensus 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.ConclusionThis study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.Level of evidenceV     

Conversion of biarticular to monoarticular muscles as a component of multilevel surgery in spastic diplegia

We treated 20 children (40 limbs) with diplegic cerebral palsy who could walk by multilevel soft tissue operative procedures including conversion of the biarticular semitendinosus and gastrocnemius to monoarticular muscles. The mean age at surgery was 11.5 years (5.6 to 17.0). All patients underwent clinical and radiological examination and three-dimensional instrumented gait analysis before and at a mean of 3.1 years (2.0 to 4.5) after surgery. The passive range of movement at the ankle, knee and hip showed improvement at follow-up. Kinematic parameters indicated a reduced pelvic range of movement and improvement of extension of the knee in single stance after operation (p < 0.0001). However, post-operative back-kneeing was detected in five of the 40 limbs. The kinetic studies showed that the power of the hamstrings and plantar flexors of the ankle was maintained while the maximum knee extensor moment during stance was reduced. The elimination of knee flexor activity of semitendinosus and gastrocnemius combined with transfer of distal rectus femoris led to an improvement in gait as confirmed by gait analysis.     

Selective lengthening of the psoas and rectus femoris and preservation of the iliacus for flexion deformity of the hip in cerebral palsy patients

Between 1978 and 1983, 52 Japanese patients with cerebral palsy underwent operative correction of flexion deformity of the hip. The results of lengthening of the psoas, rectus femoris, and proximal hamstrings were satisfactory. The iliacus was left intact. Improvement in gait and activities of daily living was attained. Concentric reduction was obtained in 27 of 33 dislocated or subluxated hips. Sitting and perineal care were facilitated, and pain was alleviated. We conclude that preservation of the iliacus is important.     

Spastic hemiplegic cerebral palsy and the femoral derotation osteotomy: effect at the pelvis and hip in the transverse plane during gait

Gait analysis techniques were used to evaluate the outcome of the femoral derotation osteotomy in children with hemiplegic cerebral palsy. Seventy-one patients were evaluated and classified according to the Winters and Gage scale. Nine of the 13 patients classified as type IV underwent a femoral derotation osteotomy. Postoperatively, all nine patients demonstrated less internal hip rotation, pelvic retraction, and internal foot progression angle. Before surgery patients improve the foot progression by an externally biased hip position within the hip rotation arc. After surgery the hip position is allowed to be more centered within the rotation arc without compromising foot progression. Interestingly, the changed hip position during gait was significantly less than the magnitude of the derotation osteotomy. When contemplating postoperative outcome, consideration of hip position within the arc of rotation and pelvic retraction should be given to avoid undercorrection and residual pelvic compensation with femoral osteotomy based solely on foot progression.     

Rectus transfer in spastic diplegia

Objectives  

Change of function of the rectus femoris through medial transfer of its distal tendon. This procedure transforms a hip flexor and knee extensor into a hip and knee flexor. Thus the muscle acts as a hip flexor during the terminal stance phase and swing phase and as a knee flexor during the swing phase. This permits the foot to clear the ground and to improve the spastic gait.     

Rectus Femoris Transfer Improves Stiff Knee Gait in Children With Spastic Cerebral Palsy

Background  

Stiff knee gait is common among children with ambulatory cerebral palsy (CP). When surgery is indicated, rectus femoris transfer as a primary treatment enhances knee range of motion, reduces time to peak knee flexion, increases peak knee flexion, and reduces toe drag.     

Factors associated with internal hip rotation gait in patients with cerebral palsy

Internal rotation gait is common in children with cerebral palsy. Factors thought to contribute include femoral anteversion, hip flexor tightness, imbalance of hip rotators, and hamstring and adductor tightness. The exact cause of internal rotation must be defined before contemplating surgery. We investigated the prevalence of internal hip rotation and associated factors, which are considered to influence this walking pattern, in patients with cerebral palsy. Gait laboratory data of 222 patients with cerebral palsy were studied retrospectively. Two groups were selected; those with maximum dynamic hip internal rotation of more than 27 degrees and those with less than 20 degrees. Of 222 patients, 27.0% (diplegia, 61.7%; hemiplegia, 38.3%) had at least one hip with dynamic internal rotation of more than 27 degrees. This study suggests that dynamic hip internal rotation is multifactorial in origin. The most significant differences in clinical measures were found in values of passive hip external rotation range, femoral anteversion and hip flexor contracture. We discuss the role of early treatment of hip flexion contracture.     

Surgical treatment of knee dysfunction in cerebral palsy

The prerequisites for normal gait are: (1) stability in the stance phase of gait, (2) clearance of the foot in the swing phase, (3) proper foot preposition in swing, and (4) an adequate step length. In the stance phase, the knee provides shock absorption and energy conservation; in the swing phase, it allows foot clearance. To accomplish these functions, the knee must extend fully in stance and flex approximately 60 degrees in swing. Consequently, balanced muscle action at the hip, knee, and ankle joints, combined with adequate acceleration from the hip flexor and triceps surae muscles, is essential. In the crouch gait of spastic cerebral palsy, hamstring lengthening alone often converts the flexed-knee gait to an extended-knee, stiff-legged gait with inadequate swing-phase knee flexion. This unwanted conversion is due to cospasticity of the quadriceps and hamstring muscles. Restoration of normal knee function in patients with spastic paralysis is more successful when fractional hamstring lengthening is combined with a transfer of the distal rectus femoris tendon to either the iliotibial band or the distal tendon of the semitendinosus.     

Effects of intramuscular psoas lengthening on pelvic and hip motion in patients with spastic diparetic cerebral palsy

The effects of intramuscular psoas lengthening on gait in cerebral palsy patients have been the subject of debates, and the indications for such procedure are still controversial. The purpose of this study was to evaluate the effects of intramuscular psoas lengthening on sagittal plane pelvic and hip motion in patients with spastic diparetic cerebral palsy and identify the factors linked to the best possible outcome. A retrospective study was performed in 26 independent ambulatory patients. All of them had undergone an intramuscular psoas lengthening over the pelvic brim. The mean age at the time of surgery was 11.10 years, and most cases went through additional simultaneous procedures. A complete gait analysis was performed before and, on average, at 17.69 months (range, 6-39 months) after surgery. The Thomas test values, maximum hip extension in stance, and pelvic tilt were analyzed before and after surgical intervention, and the results were statistically compared. The most significant postoperative effect was the reduction of pelvic range of motion (P < 0.01). Reduction of anterior pelvic tilt was observed only in those patients with no previous need of an external aid (P < 0.01), and the studied group did not show a significant improvement of hip extension at terminal stance. According to the results, intramuscular psoas lengthening was useful in reducing pelvic range of motion at the sagittal plane, but this study also suggests that pelvic and hip disruptions of the same plane (sagittal) seem to have a multifactorial etiology. The use of external assistive devices in patients with balance problems may lead to increased anterior pelvic tilt as well as reduction of hip extension at terminal stance.     

Three-dimensional muscle-tendon geometry after rectus femoris tendon transfer

BACKGROUND: Rectus femoris tendon transfer is performed in patients with cerebral palsy to improve knee flexion during walking. This procedure involves detachment of the muscle from its insertion into the quadriceps tendon and reattachment to one of the knee flexor muscles. The purpose of the present study was to evaluate the muscle-tendon geometry and to assess the formation of scar tissue between the rectus femoris and adjacent structures. METHODS: Magnetic resonance images of the lower extremities were acquired from five subjects after bilateral rectus femoris tendon transfer. A three-dimensional computer model of the musculoskeletal geometry of each of the ten limbs was created from these images. RESULTS: The three-dimensional paths of the rectus femoris muscles after transfer demonstrated that the muscle does not follow a straight course from its origin to its new insertion. The typical muscle-tendon path included an angular deviation; this deviation was sharp (>35 degrees ) in seven extremities. In addition, scar tissue between the transferred rectus femoris and the underlying muscles was visible on the magnetic resonance images. CONCLUSIONS: The angular deviations in the rectus femoris muscle-tendon path and the presence of scar tissue between the rectus femoris and the underlying muscles suggest that the beneficial effects of rectus femoris tendon transfer are derived from reducing the effects of the rectus femoris muscle as a knee extensor rather than from converting the muscle to a knee flexor. These findings clarify our understanding of the mechanism by which rectus femoris tendon transfer improves knee flexion.     

The effects of hamstring lengthening on hip rotation

The purpose of this study is to determine the effect on hip rotation of hamstring lengthening as measured by preoperative and postoperative motion analysis. Thirty-eight patients/76 hips in children with cerebral palsy spastic diplegia were retrospectively reviewed using presurgical and postsurgical gait analysis. Physical examination and gait analysis showed an increase in knee extension and decreased popliteal angles postoperatively. Kinematic analysis showed an increase in knee extension and decreased hip internal rotation throughout the gait cycle postoperatively as well. No difference was seen between those with internal and external rotation pattern at the hip preoperatively. As a group, the patients did not improve enough to change from internal to external rotation at the hip, suggesting that children with cerebral palsy spastic diplegia with significant internal rotation gait should have other surgical options besides hamstring lengthening when internal rotation gait of the hip is to be treated.     

内侧腘绳肌延长术对双侧痉挛性脑瘫下肢肌肉长度的影响

目的 观察内侧胭绳肌延长术对双测痉挛性脑瘫下肢肌肉长度的影响.方法 将双测痉挛性脑瘫患者分为两组,一组为髂腰肌组5例(10侧肢体),即内侧胭绳肌延长,股直肌远端转位加髂腰肌延长术.另一组为非髂腰肌组5例(10侧肢体),即内侧胭绳肌延长,股直肌远端转位术.利用计算机模拟骨肌肉步态模型技术,选择性计算术后下肢相关肌肉的肌肉长度,并对比分析.结果 髂腰肌组中患者的股二头肌长头肌肉长度,在步态周期中的平均值、最小值和总长度分别为0.5000±0.0080、0.4800±0.0059、50.8600±0.8084,明显长于非髂腰肌组患者(P＜0.05).股二头肌短头肌肉长度最小值在步态周期中所出现的时间(81.6700±4.3221)%GC,较非髂腰肌组患者(75.1300±1.8851)%GC明显延迟(P＜0.01),半腱肌和半膜肌肌肉长度最小值在步态周期中出现的时间分别为(72.6700±3.0768)%Gc和(73.0000±3.6332)%GC,较非髂腰肌组出现的时间(68.500±1.5119)%Gc和(68.1300±1.5526)%Gc明显延迟(P＜0.05).结论 屈髋肌挛缩组患者在施行内侧胭绳肌延长、股直肌远端转位和髂腰肌延长术后,出现胭绳肌功能不全模型的原因,是由于外侧腘肌肌肉长度较长和内侧腘绳肌肌肉长度相对较长.     

Analysis of two different techniques in the treatment of knee stiffness in swing phase due to fibrous rectus femoris muscle in children

The objective of this study was to analyze two surgical techniques in the treatment of fibrous rectus femoris muscle in children. Data from 152 patients (161 knees) from July 1991 to December 2004 were analyzed. Clinical signs were knee stiffness in swing phase, positive Ely and Ober tests, and abnormal flexion angles of the knee and hip. Patients were operated according to one of two variants: variant A, to release the proximal tendon and variant B, to release the middle shaft of the rectus femoris muscle. There were 96 women (63.2%) and 56 men (36.8%) in this study. Bilateral involvement was found in nine patients; only the left knee was affected in 34 patients (22.4%) and only the right knee in 109 patients (71.7%). All 152 patients (161 knees) developed fibrous rectus femoris muscle (RFM) after repeated intramuscular injection of antibiotic(s) into the RFM. A total of 145 knees (136 patients) were classified as severe and 16 knees (16 patients) were classified as moderate. Overall, we attained excellent results in 109 (67.7%), good results in 26 (16.1%), fair results in 14 (8.7%), and poor results in 12 knees (7.5%). There have been no complications so far. Generally, surgical treatment of knee stiffness in swing phase due to fibrous RFM according to variant B led to postoperative poor results in only 1.2% of patients, whereas variant A gave postoperative poor results in 14.5% of patients. The surgical procedure is simple and safe, and knee and hip functions, tendency for crouch gait, and anterior pelvic tilt were remarkably improved.     

Rectus femoris transfer for children with cerebral palsy: long-term outcome

The purpose of this study was to evaluate the long-term results of rectus femoris transfer in cerebral palsy children with stiff-knee gait. Thirty-eight affected limbs in 24 children were evaluated preoperatively and 1 year postoperatively by gait analysis, with 26 limbs in 18 patients having final study, averaging 4.6 years postoperatively. Functional ambulatory status was evaluated based on Hoffer's criteria on ambulation. There were statistically significant improvements of 9.8 degrees in maximum swing-phase knee flexion and 7.0 degrees in total range of knee motion at 1 year, with a small loss of knee extension in stance. At final gait analysis, the improvement in the swing-phase knee flexion was maintained, but improvement in total range of knee motion was decreased. There were no significant changes in temporal parameters. Improvement in swing-phase knee flexion and foot clearance after rectus femoris transfer was associated with loss of knee extension at long-term follow-up. Hamstring lengthening in patients who develop excessive stance-phase knee flexion may be necessary.     

Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients

Background There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning.

Method Before gait analysis, 60 ambulatory children aged 10 (4-18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis.

Results Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%).

Interpretation Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.     

Hip dysplasia in spastic cerebral palsy

Previous reports have noted a relationship between pelvic obliquity and hip dysplasia in spastic cerebral palsy but did not confirm its existence by scientific study. A study is reported that confirms the association of pelvic obliquity with hip dysplasia in spastic cerebral palsy. At presentation of subluxation or dislocation prior to surgery, 80 patients were indexed into five body alignment types. Reclassifications were performed with passage of time in order to study the natural history and effects of surgery. In all cases, hip dysplasia was found to be consistent with the forces related to pelvic obliquity.